Skip to main content

Full text of "A text-book of legal medicine and toxicology"

See other formats


A  TEXT-BOOK  OF 
LEGAL  MEDICINE 
AND  TOXICOLOGY 


EDITED    BY 

FREDERICK  PETERSON,  M.D. 

President  of  the  New  York  State  Commission  in  Lunacj' ;  Chief  of  Clinic,  De- 
partment for  Nervous  Diseases,  Cohiinbia  University  ;  General 
Consultant  to  the  Craig  Colony  for  Epileptics, 
Soayea,  New  York 

AND 

WALTER  S.  HAINES,  M.D. 

Professor  of  Chemistry,  Pharmacy,  and  Toxicology  in  Rush  ^Medical  College, 

Chicago  ;  Professorial  I,ecturer  on  Toxicology  in 

the  University  of  Chicago 


51n  ^U)o  IJolumcs? 

Containing  about  1500  ]p>aocs",  J^uH^  JHustiatcD 


VOLUME     I 


PHILADELPHIA   AND   LONDON 

W.    B.    SAUNDERS    &    COMPANY 

1Q03 


Copyright,  1903.  by  W.  B.  Saunders  &  Company, 


Registered  at  Staiioners'  Hall,  London,  England. 


I 


EUECTROTYPED    BY 
WEETCOTT   &.   THOMSON,    PHILAO*. 


PRESS    OF 
W.    B.    SAUNDERS   &.    CO.,    PHJLADA 


CONTRIBUTORS  TO  VOLUME  I. 


SAMUEL  TREAT  ARMSTRONG,  M.  D.,  Ph.  D.,  Xew  York  City. 

Medical  luspector,  Washington  Life  Insurance  Co.,  Xew  York. 

PEARCE  BAILEY,  M.  D.,  "  New  York  City, 

Consulting  Neurologist  to  the  St.  Luke's  and  Roosevelt  Hospitals,  New  York  City ; 
Instructor  in  Neurology,  Columbia  University,  New  York  City. 

LEWIS  BALCH,   M.  D.,  Pii.  D.,  Ne\y  York  City. 

Late  Professor  of  Medical  Jurisprudence  and  Hygiene,  Albany  Medical  College ; 
late  Brigade  Surgeon,  United  States  Volunteers,  etc. 

CHARLES  GILBERT  CHADDOCK,  M.  D.,  St.  Louis. 

Professor  of  Diseases  of  the  Nervous  System,  Marion-Sims-Beaumout  College  of 
Medicine,  St.  Louis. 

JOHN  CHALMERS  DaCOSTA,  M.  D.,  Philadelphia. 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical 
College,  Philadelphia  ;  Surgeon  to  the  Philadelphia  Hospital. 

J.  T.  ESKRIDGE,  M.  D.,i  Denver. 

Late  Consulting  Alienist  and  Neurologist,  Arapahoe  County  Hospital ;  late  Neurolo- 
gist to  St.  Luke's  Hospital,  Denver. 

JAMES  EWING,  M.  D.,  New  York  City. 

Professor  of  Pathology,  Cornell  University  Medical  College,  New  York  City. 

WALTER  S.  HAINES,  M.  D.,  Chicago, 

Professor  of  Chemistry,  Pharmacy,  and  Toxicology  in  Rush  Medical  College,  Chicago ; 
Professorial  Lecturer  on  Toxicology  in  the  University  of  Chicago. 

JOSIAH   N.  HALL,  M.  D.,  Denyer. 

Profes.sor  of  Medicine  in  the  Denver  and  Gross  College  of  Medicine ;  Vi.siting  Phy- 
sician to  the  Arapahoe  County  Hospital ;  Member  of  the  Medico-Legal  Society  of 
New  York,  of  the  American  Therapeutic  Society,  etc. 

GRAEME   M.    HAMMOND,  LL.B.,  M.  D.,  New  York  City. 

Professor  of  Nervous  and  Mental  Diseases  in  the  New  York  Post-Graduate  Medical 
School  and  Hospital;  Neurologist  to  the  Charity  Hospital,  New  York  City. 

LUDVIG  HEKTOEN,  M.  D.,  Chicago. 

Professor  of  Pathology  in  the  University  of  Chicago. 

1  Deceased. 


4  CONTEIBUTOES    TO    VOLUME    I. 

EDWAED  JACKSON,   A.M.,  M.  D.,  Denver. 

Emeritus  Professor  of  Diseases  of  the  Eye  iu  the  Philadelphia  Polyclinic ;  Ophthal- 
mologist to  the  Arapahoe  County  Hospital,  Denver,  Col. 

SMITH   ELY  JELLIFFE,    A.M..  M.  D.,  Ph.D.,  New  York  City. 

Visiting  Neurologist,  City  Hospital.  New  York;  Clinical  Assistant,  Columbia  Uni- 
versity, New  York,  Department  of  Neurology ;  Professor  of  Pharmacognosy.  Col- 
lege of  Pharmacy,  City  of  New  York ;  Managing  Editor,  Journal  of  Nervous  and 
Mental  Diseases,  New  York. 

F.  W.  LANGDON,   M.  D.,  Cixcixxati. 

Professor  of  Nervous  and  Mental  Diseases  in  Miami  Medical  College  and  in  the 
Laura-Memorial  Woman's  Medical  College  of  Cincinnati ;  Neurologist  to  the  Cincin- 
nati Hospital,  the  Presbyterian  Hospital,  Christ's  Hospital,  and  the  Ophthalmic 
Hospital  of  Cincinnati ;  Consulting  Neurologist  to  the  Episcopal  Hospital  for  Children. 

FREDERICK  PETERSON,  M.  D.,  New  York  City. 

President  of  the  New  York  State  Commission  in  Lunacy ;  Chief  of  Clinic,  Depart- 
ment for  Nervous  Diseases,  Columbia  University  ;  Instructor  in  Mental  Diseases, 
Columbia  University ;  General  Consultant  to  the  Craig  Colony  for  Epileptics  at 
Sonyea,  New  York  ;  Ex-President  of  the- New  York  Neurological  Society. 

ALLEN  J.  SMITH.  A.M..  M.D..  Galveston. 

Professor  of  Pathology,  University  of  Texas,  Galveston,  Texas. 


PREFACE. 


The  object  of  the  present  work  is  to  uive  to  the  medical  and  legal 
professions  a  fairly  comprehensive  snrvey  of  forensic  medicine  and  toxi- 
cology in  moderate  compass.  We  l)elieve  this  has  not  been  done  in  any 
very  recent  work  in  English.  A  nnml)er  of  mannals  of  limited  size  and 
scope  have  been  presented  on  the  one  hand,  and  on  the  other  certain 
svstems  of  legal  medicine  of  almost  encyclopedic  dimensions.  Both 
find  fields  of  great  usefnlness  ;  but  there  is  still  left  a  broad  ground 
intermediate  between  the  tw(j  which  wc  trust  the  present  work  will  fill, 
and  it  was  in  this  hope  that  the  book  has  been  planned  and  executed. 

With  few  and  wholly  unimportant  exceptions  the  articles  composing 
the  two  volumes  have  been  inserted  without  change  by  the  editors. 
This  has  been  done  in  order  that  the  responsibility  for  statements  of 
facts  and  opinions  may  be  authoritatively  placed  u])()n  the  individual 
contributors — a  matter  of  much  moment  in  legal  proceedings.  In 
doing  this  we  are  aware  that  we  have  occasionally  sacrificed  unity  of 
plan  and  harmony  of  views,  l^ut  the  advantages,  especially  to  the  legal 
profession,  of  individual  responsibility  we  believe  much  more  than  com- 
pensate for  these  defects. 

As  the  ordinary  English  weights  and  measures  and  the  Fahrenheit 
thermometer  scale  are  still  the  only  ones  easilv  understood  bv  the  ma- 
jority  of  courts  and  juries,  we  have  generally  used  these  measures, 
wholly  or  in  conjunction  with  their  equivalents  in  metric  weights  and 
measures  and  the  Centigrade  scale.  This  rule,  however,  has  not  been 
followed  in  the  description  of  purely  chemical  tests  and  processes,  as 
the  metric  system  is  practically  universally  employed  in  connection' 
with  them. 

In  the  names  of  drugs  and  chemicals  we  have  followed  the  nonjen- 
clature  and,  with  slight  modifications,  the  spelling  of  the  United  States 
Pharmacopeia,  believing  that  by  adhering  to  so  anthoritative  and  well 
known  a  standard  as  this  much  confusion  will  be  avoided  and  a  not  in- 
frequent source  of  perjilexity  to  lawyers  and  physicians  eliminated. 

The  work  is  divided,  for  convenience  of  reference,  into  two  sections, 
Part  I.  and  Part  IL,  the  latter  being  devoted  to  Toxicology,  and  all  other 
portions  of  Legal  ^Medicine  in  which  laboratory  investigation  is  an  essen- 
tial feattire. 

Our  thanks  are  due  to  the  many  distinguished  men  who  have  aided 
us  in  the  production  of  the  work  by  their  valuable  contrilnitions  ;  and 
we  are  greatly  indebted  to  the  ])ublishers,  ^Messrs.  "W.  B.  Saunders  & 
Co.,  for  the  unfiiling  interest  they  have  shown  in  the  book,  and  for  the 
numerous  courtesies  they  have  extended  to  us  in  its  preparation. 

FREDERICK  PETERSON, 
WALTER  S.  HAINES. 

5 


CONTENTS  OF  VOLUME  I. 


PART  I. 

PAGE 

IXTRODLXTIOX;    EXPERT   EVIDEXCE   (By   Frederick    Peterson-   and 

Walter  S.  Haines) 15 

Detinition  of  legal  medicine,  15 — Exjiert  witnesses,  15 — Sources  of  error  in 
expert  evidence,  16 — Selection  of  expert  witnesses,  18 — Advice  to  medical 
experts,  19 — Suggestions  to  attorneys,  21. 

THETECHXIC  OF  MEDICOLEGAL  POSTMORTEM  EXAMINATIOX  (By 

LiTDViG  Hektoen) 23 

Instruments  and  utensils,  23 — The  record,  26 — Examination  of  the  body,  27 — 
Inspection  of  the  body,  27 — Inspection  in  the  case  of  unknown,  burned,  and 
decomposed  bodies,  30 — Inspection  of  the  surroundings  of  the  body,  31 — 
Examination  of  frozen  bodies,  31 — Examination  of  embalmed  bodies,  31 — 
Internal  examination.  31 — Order,  31 — Cranial  cavity,  33 — Brain,  35 — Spinal 
column  and  cord,  38 — Orbits,  40 — Eai-s,  40- — Xas;il  and  accessory  cavities,  40 — 
Opening  the  cavities  of  the  trunk,  41 — The  organs  of  the  neck,  43 — The  organs 
of  the  thorax,  44 — The  lungs,  44 — Pericardium,  44 — Heart,  45 — The  organs 
of  the  abdomen,  49 — Spleen,  49 — Region  of  the  gall-Vdadder  and  biliary  ducts, 
50 — Liver  and  gall-bladder,  50 — Kidneys  and  adrenals,  51 — Pelvic  viscera,  52 
— Rectum,  52 — Stomach  and  duodenum,  53 — Pancreas,  54 — Intestines,  54 — 
Retroperitoneal  structures,  55 — Extremities,  55 — Examination  in  cases  of  sus- 
pected poisoning,  55 — Examination  of  new-born  children,  57 — Restoration  of 
the  body,  60. 

IDEXTITY  (By  James  Ewing) 62 

General  statement,  62 — Age,  65 — Race,  70 — Stature,  71 — Sex,  74 — Occupation, 
76— The  hair,  77— The  teeth,  81— The  skin,  83— Scars,  83— Tattoo-marks,  88— 
Finger-prints,  90  —  Foot-prints,  92  —  Handwriting,  93  —  Photographs,  94  — 
General  likeness,  94 — Peculiarities  of  special  senses,  96 — The  systematic  regis- 
tration of  crinunals,  97 — Bertillon  system,  97 — Identification  of  mutilated 
remains,  99 — Examination  of  the  mind,  101. 

THE  SIGNS  OF  DEATH  (By  James  Ewixg) 104 

Special  signs  of  death,  107 — Cadaveric  changes,  112. 

SUDDEN  DEATH  (By  James  Ewing) 138 

Consideration  of  the  visceral  changes  leading  to  sudden  death,  139 — Shock,  141 
— Svncope,  141 — Presumption  of  death,  154 — Presumption  of  survivoi"ship,  155. 

DEATH  FROM  COLD,  HEAT,  AND  STARVATION  (By  Allen  J.  Smith)   .    161 
Death  from  cold  and  heat,  161 — Death  from  cold,  165 — Death  from  heat,  173 — 
Death  frnrn  starvation,  179 — Death  from  thirst,  185. 

7 


8  CONTENTS    OF    VOLUME    I. 

PAGE 

DEATH  FROM  ASPHYXIA  (By  Allen  J.  Smith)       187 

Death  by  strangulation,  190 — Death  by  throttling,  190 — Death  by  hanging, 
197 — Death  l^y  choking,  208 — Choking  by  solids,  209 — Death  by  submersion, 
213 — Deatli  from  clicking  by  gaseous  matter,  226 — Carbonic  acid  gas,  226 — 
Death  by  sufibcation,  229 — Suflbcation  from  external  causes,  230 — Suflbcation 
from  causes  operating  internally,  237  —Carbon  monoxid,  237 — Sulphureted 
hydrogen,  244 — Arsenureted  hydrogen,  244. 

DEATH  AXD  INJURIES  BY  LIGHT1vT:NG  AND  ELECTRICITY  (By  Smith 

Ely  Jelliffe) 245 

Historic  introduction,  245 — Resistance  of  tlie  body,  240 — Grades  of  accident 
and  injury,  248 — Minor  mjuries  from  lightning,  250 — Pathology,  251 — Internal 
pathologic  lesions  due  to  lightning,  254 — Internal  lesions  in  death  due  to  in- 
dustrial electricity,  254 — Causes  of  death  by  electricity,  259 — Certain  questions 
of  death  and  recovery,  262. 

WOUNDS  (By  Leato  Balch) 264 

Kinds  of  wounds,  265 — Wounds  dangerous  to  life,  266 — Wounds  on  the  dead 
body,  266 — ^Vounds  on  the  living,  268 — Contusions,  268 — Incised  wounds,  270 
— Punctured  wounds,  273 — Lacerated  wounds,  275 — Poisoned  wounds,  276 — 
Fractures  and  dislocations,  277 — Evidence  of  wounds,  weapons,  and  other 
articles,  279 — Suicide,  286 — Accidental  wounding,  288 — Regional  wounds,  288 
—Head,  288— Face,  294— Neck,  295— Spine,  295— Chest,  297— Diaphragm, 
299^Abdomen,  299 — Pelvis  and  contents,  303 — Genital  organs,  305 — Ex- 
tremities, 305. 

GUNSHOT  WOUNDS:  BURNS  AND  SCALDS  (By  Josiah  N.  Hall)  ...  308 
Gun.shot  wounds,  308 — Deflection  of  bullets,  309 — Character  of  gunshot  wounds, 
311 — Shotgun  wounds,  311 — Was  the  wound  inflicted  by  firearms?  312 — Is  the 
wound  mortal  or  dangerotts  to  life?  314 — Immediate  cause  of  death,  314 — 
How  soon  will  the  wound  cause  death?  314 — Was  the  wound  inflicted  during 
life?  315 — How  long  since  death  occun-ed?  315 — Survivorship,  315 — Would 
the  wound  cause  unconsciousness?  315 — How  long  since  the  weapon  was  fired? 
318 — Accidental  wounds,  318 — Was  the  wound  accidental,  suicidal,  or  homi- 
cidal ?  319 — Examination  of  weapon,  body,  and  surroundings,  321 — From 
what  direction  was  the  ball  fired  ?  323 — Recognition  by  flash  of  weapon,  324 — 
Distinguishing  weapons  by  their  reports,  324— Gunshot  marks  in  clothing,  324 
— How  long  may  the  smell  of  powder  or  smoke  be  detected  in  the  room  ?  325 
— Brand,  tattooing,  estimation  of  proximity  and  position  of  weapon,  325 — 
Burns  and  scalds,  333— Period  of  death,  336 — Was  the  injury  inflicted  befoi-e 
or  after  death,  336 — Accident,  suicide,  or  homicide  ?  337 — Subsequent  results, 
338— Cicatrices,  338— Tattoo-marks,  340. 

THE    DESTRUCTION     AND    ATTEMPTED    DESTRUCTION    OF    THE 
HUMAN    BODY  BY  FIRE   AND    CHEMICALS    (By  Walter  S. 

Haines) 343 

Destruction  by  fire,  343 — Complete  destruction  of  the  body  by  fire,  343— Time 
and  amount  of  fuel  i-equired,  343 — Detennination  of  the  animal  source  of  the 
ashes,  344 — Identification  of  the  human  character  of  the  remain.s,  345 — Deter- 
mination of  age,  sex,  and  personal  identity,  346 — Were  the  burns  proditced 
before  or  after  death?  346 — Were  the  wounds  observed  produced  before  death, 
or  are  they  the  effect  of  heat?  347 — Destruction  by  chemicals,  349. 


CONTEXTS    OF    VOLUME    I.  9 

PAGE 

KAIL  WAY  INJURIES  (By  J.  Ciialmeks  Da  Costa) :j.-)4 

Sex,  356 — Age,  356 — Obesity,  356 — Habits,  356 — Temperament,  357 — Kace, 
357 — Shock  or  collapse,  357 — Deliriimi  tremens,  359 — Traumatic  delii'inm, 
delirium  nervosum,  359 — Injuries  of  tlie  back,  36U — Strains  antl  sprains  of  the 
back,  36U — Spinal  concussion  and  cord  disease  of  traumatic  origin,  361 — Dis- 
locations and  fractures  of  vertebra,  362 — Injuries  of  the  head,  363 — Concus- 
sion of  the  Ijrain,  364 — Traumatic  insanity,  365 — Injuries  of  nerves,  365 — 
Injuries  of  llie  al)domen,  366 — Injuries  of  the  chest,  367 — Strains  and  sprains, 
368 — Fractures  and  bone  disease,  369 — Dislocations  and  joint  disease,  37U — 
Simulation,  372. 

INJURIES  AND  DISORDERS  OF  THE  NERVOUS  SYSTEM  FOLLOWING 

RAILWAY  AND  ALLIED  ACCIDENTS  (By  Peaiice  Bailey)  ...  373 
Symptoms  of  organic  nervous  diseases,  377 — Paralysis,  377 — Anesthesia,  378 — 
Reflexes,  380 — Sphincter  control,  381 — Tro^jhic,  382 — Pahi,  382 — Electric 
reaction,  382 — Cerebral  symptoms,  382 — Shock,  382 — Causes,  382 — Ultimate 
results  of  organic  injury  to  the  nervous  system,  384 — Functional  disorders  of 
the  nervous  system  following  accidents,  386 — Etiology  of  traumatic  neuras- 
thenia and  hysteria,  389 — Neurasthenia,  392 — Traumatic  hysteria,  399. 

THE  MEDICAL  JURISPRUDENCE  OF  LIFE  INSURANCE  (By  S.  T.  Akm- 

strong) 418 

The  medical  examiner,  419 — Professional  confidence,  423 — .\.pplication,  424 — 
Warranty  and  representation,  425 — Residence,  431 — Occupation,  432 — Race, 
433 — .\ge,  433 — Social  condition,  435 — Beneficiary,  435 — Existing  insurance, 
436 — Pi-evious  rejection,  437 — Suicide,  439 — Health  when  policy  is  delivered, 
448 — Previous  liealth,  449 — Certificate  of  death,  452 — Personal  injurv.  452 — 
Asthma,  453 — Bronchitis,  453 — Cancer,  454 — Consumption,  455 — Disease^  of 
the  eye,  459 — Diseases  of  the  heart,  460 — Diseases  of  the  kidneys,  462 — Di.s- 
eases  of  the  liver,  464 — Diseases  of  the  lungs,  465 — Diseases  of  the  stojuach, 
46G — Diseases  of  the  throat,  466 — Fits  or  convulsions,  467 — General  debilitv, 
467 — Headache,  468 — Hernia,  468 — Rheumatism,  469 — Insanity,  470 — Paral- 
ysis, 471 — Piles,  472 — Spitting  or  coughing  of  blood,  472 — Sunstroke,  473 — 
Syphilis,  473 — The  use  of  wine,  spirits,  or  malt  liquors,  474 — Health  at  the 
■time  of  the  application,  478 — Attending  physician,  479 — Family  history,  480 — 
Women  as  risks,  481 

THE  MEDICAL  JURISPRUDENCE  OF  ACCIDENT  INSURANCE  (By  S. 

T.  Armstrong) 484 

The  application,  485— Warranty  and  representation,  485— Policy,  486— Health 
of  the  insured,  487— External  means,  488— Some  of  the  causes  of  accidental 
death,  490— Asphyxiation,  491— Sunstroke,  491— Hernia,  491— Suicide,  492. 

MEDICOLEGAL  ASPECTS    OF  VISION    AND   AUDITION    (By   Edward 

Jackson) 493 

Acuteness  of  vision,  493— The  field  of  vision,  494— Color-blindness,  495— 
Causes  of  blindnes.s,  496 — Feigned  blindness,  496 — The  eye  in  life  insurance, 
498 — Injuries  to  the  eye,  499 — Malpractice,  499 — Actiteness  of  hearing,  500 — 
Condition  of  the  ear  in  life  insurance,  501 — Injuries  of  the  ear,  501. 

SPEECH  DISORDERS  (By  Feaxk  Warrex  Laxgdox) 502 

Normal   speech   processes,  502 — Anatomic   basis   of   speech   processes,  503 — 


lU  CONTENTS    OF    VOLUME    I. 

PAGE 

Limits  of  legal  impairment,  506 — Ke.sponsibility  for  acts  done,  507 — Com- 
petency legally  to  perform  proposed  acts,  508 — Disordei-s  of  speech  processes, 
508 — The  receptive  or  ^<ensory  aphasias,  508 — The  intermediate  or  conduction 
aphasias,  51o — The  emissive  or  motor  aphasiass,  516 — Irregular  and  mixed 
forms  of  aphasia,  523. 

INEBKIETY  (By  Graeme  M.  Hammond) 526 

The  inebriate  and  his  contracts,  530 — Inebriety  and  life  insurance,  531 — Torts 
and  inebriety,  532 — Wills  and  inebriety,  533 — Marriage  and  inebriety,  535 — 
Divorce  and  inebriety,  536 — Breach  of  promise  to  marry,  537 — Inebriety  and 
crime,  538. 

THE  STIGMATA  OF  DEGEXEKATION  (By  Frederick  Peterson)  ....  544 
Stigmata  of  degeneration,  545 — Anatomic  stigmata,  545 — Physiologic  stigmata, 
546 — Psychic  stigmata,  540 — The  etiology  of  hereditary  stigmata,  546 — De- 
scription in  detail  of  the  stigmata  of  degeneration,  547 — Cranial  anomalies,  547 
— Chemocephalus,  549  —  Leptocephalus,  549  —  Macrocephalus.  549  —  Micro- 
cephalus,  449 — Oxycephalus,  550 — Plagiocephalus,  550 — Scaphocephalus,  550 
— Trigonocephalus,  550 — Facial  asymmetry,  556 — Deformities  of  the  palate, 
556  —  Dental  anomalies,  562  —  Anomalies  of  the  tongue  and  lips,  562  — 
Anomalies  of  the  nose,  562 — Anomalies  of  the  eye,  562 — Anomalies  of  the 
ear,  562 — Anomalies  of  the  limbs,  566 — Anomalies  of  the  body  in  general, 
567 — Anomalies  of  the  genital  organ.s,  567 — Anomalies  of  the  skin,  568 — 
Anomalies  of  motor  function,  568 — Anomalies  of  sensory  function,  568 — 
Anomalies  of  speech,  568  —  Anomalies  of  genito-urinary  function,  568 — 
Anomalies  of  instinct  or  appetite,  569 — Miscellaneous,  569 — The  medicolegal 
value  of  degenerative  stigmata,  569. 

INSANITY  (By. L  T.  Eskridge) 571 

Etiology,  571 — Pathology,  580 — Symptoms,  584 — The  physical  condition  in 
insanity,  591 — Melancholia,  595 — Mania,  600 — Katatonia,'  606 — Transitory 
frenzy,  608 — Primary  mental  stupor  or  anergia,  611 — Primary  confusional  in- 
sanity, 612 — Insanity  of  pubescence,  614 — Chronic  hysteric  insanity,  616 — 
Insanity  from  epilepsy,  617  —  Dementia  (primary  and  secondary),  622  — 
Periodic  or  circular  insanity,  626 — Paranoia,  627 — Fomis  of  insanity  asso- 
ciated with  demonstrable  brain-lesions,  635 — Delirium  grave,  635 — Alcoholic 
insanity,  638 — Insanity  from  sy^jhilis,  643 — Paretic  dementia,  647 — Senile 
dementia,  659 — Insanity  from  gross  lesions  of  the  brain  resulting  in  softening, 
660 — Mental  condition  in  states  of  arrested  cerebral  development,  661. 

IDIOCY,    IMBECILITY,    AND    FEEBLE-MINDEDNESS    (By    Frederick 

Peterson  and  Smith  Ely  Jelliffe) 663 

Definition,  66.3 — Classification  of  idiocy,  664 — Idiots,  665 — Imbecility,  666 — 
Feeble-minded,  666 — Idiots  savants,  667 — General  etiology,  667  —  General 
symptomatology,  669 — General  pathologic  anatomy,  679 — Diagnosis  and  Prog- 
nosis, 680 — General  treatment  of  idiocy,  681 — Education  of  idiots,  682. 

MENTAL  PEKVERSIONS    OF    THE  SEXUAL  INSTINCT   (By  Charles 

Gilbert  Cii.\ddock) 683 

Sexual  paradoxia,  6S9 — Sexual  anesthesia,  690 — Sexual  hyperesthesia,  690 — 
Sexual  paresthesia,  691. 

INDEX 717 


CONTENTS  OF  VOLUAIE  II. 


FEIGNED    MENTAL    AND    BODILY    DISORDERS    (IJy   J.    T.    E<kridgk  and 
Leonard  Freeman). 

PREGNANCY,  BIRTH,  DELIVERY,  AND  SEX  (By  W.  A.  Newman  Dorlaxd). 

LEGITIMACY    AND    DURATION    OF    PREGNANCY    (By    AV.    A.    Newman 
Dori.and). 

BIRTH  AND  LEGITIMACY  (By  Joseph  F.  Darlixo  and  A.  L.  GuLinvAXER). 

ABORTION  (By  Edward  P.  Davis). 

INFANTICIDE  (By  Edward  P.  Davis). 

IMPOTENCE,     STERILITY,     RAPE,     AND     UNNATURAL    OFFENSES     (By 
Charles  Gilbert  Chaddock). 

MEDICOLEGAL  RELATIONS  OF  VENEREAL  AND  GENITO-URINARY  DIS- 
ORDERS (By  George  K.  Swinbcrxe). 

MARRIAGE  AND  DIVORCE  (By  Joseph  F.  Darling  and  A.  L.  Goldwatkr). 

MALPRACTICE,  CIVIL  AND  CRIMINAL  (By  Marshall  D.  Ewell). 

X-RAYS:  THEIR  MEDICOLEGAL  RELATIONS  (By  Harold  N.  Mover). 

LAWS  OF  THE  VARIOUS  STATES  RELATING  TO  THE  COMMITMENT  AND 
RETENTION  OF  THE  INSANE  (Bv  Carlos  MacDonald). 


PART  II. 


GENERAL  PRINCIPLES  OF  TOXICOLOGY  (By  Walter  S.  Haines). 

INORGANIC  POISONS  (By  James  W.  Holland). 

ALKALOIDAL  POISONS  (By  Albert  B.  Prescott). 

NON-ALKALOIDAL  ORGANIC  POISONS  (By  Reid  Hint  and  Walter  Jones). 

GASEOUS  POISONS  (By  Charles  A.  Doremcs). 

FOOD  POISONS  (By  Charles  Harrington). 

POSTMORTEM  IMBIBITION  OF  POISONS  (By  Victor  C.  Vaxghan). 

PTOMAINS  IN  THEIR  RELATION  TO  TOXICOLOGY  (By  Victor  C.  VAiGn.AN). 

MEDICOLEGAL  EXAMINATION  OF  BLOOD  AND  BLOOD-STAINS  (By 
Edward  S.  Wood). 

MEDICOLEGAL  EXAMINATION  OF  SEMINAL  STAINS  (By  Edward  S- 
W^ood). 

MEDICOLEGAL  EXAMINATION  OF  HAIRS  (By  William  T.  Belfield). 

DEATH  FROM  POWDERED  GLASS  AND  OTHER  MECHANICAL  IRRI- 
TANTS (By  Walter  S.  Haixes  and  Jerome  H.  Salisbury). 

RESPONSIBILITY  OF  PHARMACISTS  (By  Oscar  Oldberg  and  Jerome  Probst). 

11 


PART  L 


INTRODUCTION. 


EXPERT  EVIDENCE. 

Legal  medicine,  medical  jurisprudence,  or  forensic  medicine,  may 
be  defined  as  that  l)raiich  (^»f  juris])rudence  wliicli  pertains  to  the  elucida- 
tion and  determination  of  questions  in  law  requiring  technical  knowl- 
edge of  the  medical  sciences.  Among  the  questions  arising  at  times  in 
legal  procedures  are  such  as  concern  the  causes  of  death,  the  identity 
of  the  living  and  the  dead,  the  results  of  Avounds  and  injuries  of  all 
kinds,  life  and  accident  insurance,  mental  incompetence  from  various 
causes,  malingering,  legitimacy,  abortion  and  infanticide,  im])otence, 
sterility  and  unnatural  offenses,  marriage  and  divoi'ce,  malpractice,  and, 
finally,  the  many  questions  in  relation  to  the  science  of  toxicolog}'. 

To  aid  in  the  elucidation  of  these  prol)lems  bef  jre  the  court,  medical 
men  who  are  especially  skilled  in  some  one  branch  or  other  of  the  medical 
sciences  are  called  upon  to  testify  as  to  their  opinions  or  as  to  the  facts 
and  the  deductions  to  be  made  from  the  facts  set  before  the  judicial 
body.  These  experts  are  general  practitioners,  specialists  in  medicine, 
surgeons,  and  chemists.  Sometimes  the  questions  are  such  that  any 
general  practitioner  of  skill  and  experience  is  qualified  to  determine 
them.  Sometimes  only  a  skilled  pathologist,  neurologist,  alienist, 
obstetrician,  surgeon,  or  chemist  is  able  to  unravel  the  intricate 
problem.  The  domain  of  scientific  medicine  has  ex])anded  so  widely 
of  late  years  that  no  single  mind  can  now  compass  the  details  of  all 
branches  of  medical  science.  The  omniscient  mind  of  the  ex])(Tt  of 
other  days  is  now  impossible.  The  literatures  of  neurology  and  toxi- 
cology as  related  to  law  have  in  themselves  become  voluminous  beyond 
the  grasj)  of  the  general  practitioner  of  medicine  or  of  any  single 
medicolegal  expert. 

The  difficulties  that  enter  into  the  interpretation  of  all  sorts  of 
matters  pertaining  to  the  art  and  science  of  medicine  are  es|)ecially 
noteworthy  in  many  departments  of  medical  juris])rudence.  There  are 
nuinerous  questions  which  must  be  decided  from  the  standpoint  of  the 
value  of  human  evidence,  and  there  are  several  conditions  which  modify 
the  value  of  evidence  and  vitiate  our  inferences  and  judgments.  There 
is  no  difficulty  with  facts  which  are  known  and  accepted  by  all  man- 
kind. The  accunmlated  experience  of  ages  has  thoroughly  silted  the 
evidence  as  to  matters  of  common  knoAvledge,  such  as  the  roundness  of 
the  earth,  the  certainty  of  death,  the  accuracy  of  figures.  But  there 
are  several  sources  of  error  in  the  critical  balancing  of  testimony  in 
relation  to  doubtful  things,  theories,  hv])otheses,  and  a   host  of  matters 

15 


1 6  INTRODUCTION . 

pertaining  to  "  the  million  acres  of  our  ignorance."  In  an  inquiry  of 
this  nature  there  are  obviously  two  important  factors  :  first,  the  quality 
of  the  phenomenon  observed  ;  second,  the  character  and  quality  of  the 
observer.  The  phenomena  we  are  called  upon  to  consider  in  forensic 
medicine  are  often  indefinite,  shadowy,  and  illusory.  The  observer 
himself  is  hampei'ed  by  the  uncertain  evidence  of  his  more  or  less 
imperfect  senses,  sometimes  by  his  undisciplined  intellect,  by  the  per- 
versions of  hazy  memory,  by  the  limitations  of  his  general  knowledge 
and  experience,  perhaps  by  the  modifying  influence  of  emotions,  and, 
very  rarely,  it  is  true,  by  a  tendency  to  delil^erate  deception  and  mis- 
representation of  the  matters  under  consideration,  ^^'e  are  constantly 
confronted  in  our  study  and  practice  of  medicine  with  the  mass  of 
our  ignorance  of  the  things  yet  to  be  known,  and  with  the  defects  and 
limitations  of  the  students  of  these  things.  Despite  this,  however,  we 
are  constantly  wresting  from  nature  her  marvelous  secrets,  and  sur- 
prising and  uplifting  the  world  Avith  our  discoveries.  It  is  interesting 
to  examine  the  practical  psychology  involved  in  the  elucidation  and 
acceptance  of  any  new  fact  or  prol)lem.  Compare  the  knowledge  of 
cerebral  localization  at  the  time  of  Hippocrates  and  at  the  present  day, 
and  contemplate  the  shifting  mass  of  ignorance  concerning  this  subject 
daring  those  twenty-three  centuries.  Think  of  the  thousand  preposter- 
ous assertions  concerning  the  brain,  the  thousand  absurdities  current, 
the  thousand  errors  promulgated,  the  work  of  the  nudtitude  of  quacks, 
philosophers,  ])sychologists,  physicians,  anatomists,  })hysiologists,  and 
pathologists,  during  all  those  centuries  before  what  seem  to  us  now 
such  simple  truths  won  the  acceptance  of  the  modern  world.  And 
with  regard  to  the  things  yet  to  be  discovered  in  this  great  imseen  and 
unknown  universe  about  us,  the  same  process  of  sifting  the  good  from 
the  bad  evidence  sjoes  ever  on  in  the  seltsame  wav. 

Quacks  and  empirics  are  with  us  still,  making  all  sorts  of  fraudulent 
claims  and  ridiculous  assertions.  VCe  have  them  in  our  own  profession 
— adventurers,  seekers  after  notoriety  and  fortune,  exploiting  some 
panacea  or  other.  On  a  plane  but  little  higher  than  this  we  have  a  class 
of  pseudo-scientists,  men  who  occupy  a  quasi-reputable  position  in  the 
profession,  and  seek  by  every  means  to  enhance  their  repittations,  even 
by  deliberate  falsification  of  their  observations,  proclaiming  new  dis- 
coveries in  pathology  and  therapeutics  which  they  know  to  be  untrue, 
but  which  they  feel  may  pass  scrutiny  for  a  long  time  because  of  the 
obscurity  of  our  scientific  data  and  the  intricacies  of  the  problems 
they  })retend  to  s(>lve.  Then  we  come  to  the  body  of  real  workers  in 
every  field  of  medical  science,  men  filled  with  that  eager  enthusiasm 
and  burning  love  of  truth  which  lead  them  to  immolate  themselves 
upon  the  liest  of  sacrificial  altars,  that  of  human  progress.  It  is 
chiefly  upon  the  errors  of  these  tliat  we  wish  to  dwell,  to  point  out 
the  conditions  which  often  vitiate  their  evidence. 

In  the  first  ])lace,  there  are  our  im]ierfect  senses — those  narrow  and 
dim  avenues  throuoh  Avhich  we  uain  all  our  knowledge  of  the  outer 
world.     They  are  more  or  less  imperfect  in  all  of  us ;    the  absolutely 


EXPERT    EVIDEXCE.  17 

uuerring  eye  and  the  invarial)ly  uiilailing  ear  have  only  a  theoretic 
existeuee  :  they  are  not  found  in  real  lite.  And  what  is  true  of  seeing 
and  hearing,  may  be  repeated  of  the  other  senses,  and  possibly  with 
even  more  emphasis.  It  is  not,  then,  to  be  wondered  at  that  the  same 
occurrence  often  produces  quite  dissimilar  impressions  on  different 
witnesses,  and  that  sometimes  no  two  persons  will  agree  in  every 
detail  in  regard  to  what  has  occurred.  A  certain  degree  of  color- 
blindness, astigmatism,  deafness,  or  other  imperfection — often  unknown 
and  frequently  only  temporary — makes  some  people  at  times  the  victims 
of  their  unreliable  senses  and  renders  them  more  or  less  untrustworthy 
observers.  But  the  senses  may  be  cultivated  like  the  muscles,  and  even 
to  a  greater  degree,  and  the  real  expert,  therefore,  is  far  less  liable  to 
errors  of  observation  than  the  untrained,  and  it  is  this  fact  largely  that 
gives  to  true  expert  evidence  its  great  value. 

It  is  not  alone  the  illusions  to  which  our  defective  senses  are  so 
subject  that  lead  to  mistakes  and  misinterpretations,  but  there  are  even 
greater  sources  of  error  in  the  psychic  processes  connected  with  these 
faulty  senses.  There  are  few  observers  who  possess  that  disciplined  intel- 
lect, that  even  temperament,  that  calm  judgment,  so  necessary  to  the  criti- 
cal and  unprejudiced  examination  of  phenomena.  Many  medical  men 
have  limited  horizons,  owing  to  a  lack  of  thorough  training  and  to  a 
want  of  familiarity  with  the  ascertained  data  of  the  many  cognate 
sciences  with  which  their  own  lines  of  research  are  more  or  less  corre- 
lated. They  are,  in  other  words,  deficient  in  their  store  of  experiences. 
Another  defect  lies  in  want  of  the  imaginative  facultv.  In  studving 
the  unknown  we  may  be  handicapped  by  an  inability  to  conceive  of 
the  qualities  and  character  of  the  phenomena  that  are  hidden,  by  an 
unconsciousness  of  the  very  existence  of  such  phenomena. 

Still  another  fallacy  in  our  interpretation  of  phenomena  is  due  to 
the  vitiating  influence  of  the  emotions  upon  the  judgment.  A  man's 
character  has  been  said  to  be  the  sum  of  his  ethical  emotions,  and  his 
judgment  of  natural  phenomena,  especially  of  what  we  may  terra 
preternatural  phen(jmena,  is  almost  sure  to  be  biased  in  some  degree  by 
the  feelings  of  fear,  pleasure,  reverence,  awe,  sympathy,  or  antipathy 
which  they  inspire.  These  feelings  of  his  are  a  reflex  of  the  sum  of 
his  emotional  sensations  experienced  throughout  his  whole  life  in  rela- 
tion to  events,  customs,  religious  views,  and  all  sorts  of  convictions 
and  beliefs.  Another  and  very  intangible  source  of  error  in  evidence, 
particularly  in  regard  to  occult  phenomena,  has  been  described  as  "  the 
instinctive  tendency  of  the  imagination  to  dramatic  unity  and  complete- 
ness." A  pathologist  begins  a  difficult  piece  of  work,  and  in  his  eager- 
ness and  impatience  to  bring  it  to  a  successful  issue  he  unconsciously 
perverts  the  evidence  presented  to  fit  some  preconceived  theory  or  idea, 
shaping  it  into  a  harmonious  unity. 

So  to  sum  up,  the  chief  sources  of  error  in  evidence  as  to  even 
tangible  and  palpable  phenomena  and  flicts,  such  as  those  of  })hysiology, 
diagnosis,  pathology,  therapeutics,  forensic  medicine,  statistics,  and  the 
like,  are  very  great  and  far-reaching.      They  consist  of: 

Vol.  I.— 2 


18  INTRODUCTION. 

1.  Deliberate  fraud,  as  in  all  species  of  quackery. 

:2.  Wilful  perversion  of  facts  by  pseudoscientists. 

3.  Objective  errors  through  limitation  and  defect  of  the  senses. 

4.  Limited  horizon  through  defective  experience  and  education. 

5.  Insufficience  of  the  imaginative  faculty. 

6.  Vitiation  of  evidence  under  influence  of  the  emotions. 

7.  The  innate  tendency  of  the  mind  to  completeness,  to  dramatic 
unity  in  unraveling  a  mystery. 

The  great  progress  of  the  last  fifty  years  in  scientific  medicine  has 
been  manifested  also  in  an  elevation  of  tlie  principles  of  forensic 
medicine.  Many  questions  upon  which  formerly  there  would  have  been 
a  diiference  of  opinion  between  doctors  have  now  become  established 
facts.  We  have  a  better  knowledge  and  a  better  class  of  experts  to  aid 
in  the  cause  of  justice.  But  even  so,  there  is  much  improvement  to  be 
desired,  and  expert  testimony  has  still  a  reputation  for  uncertainty  and 
difference  which  better  methods  in  the  selection  of  the  exjiert  witnesses 
and  better  methods  of  presentation  of  their  really  valuable  testimony 
before  the  tribunal  will  finallv  overcome.  Among  the  evils  of  the 
present  system  is  that  in  some  departments  of  legal  medicine  physicians 
who  are  really  not  experts  in  the  true  sense  of  the  word  can  still 
qualify  as  such.  A  professorship  of  therapeutics  and  of  insanity  in 
an  unimportant  medical  school,  the  honorary  position  of  consulting 
physician  to  an  asylinn,  or  the  position  of  a  coroner's  ])hysician,  does  not 
really  qualify  a  physician  as  an  expert  alienist  or  pathologist,  and  yet  the 
ct)urt  generally  recognizes  such  nominal  insignia  of  office  as  evidence 
of  fitness  to  testify,  though  the  professor  of  therapeutics  may  have  no 
practical  knowledge  of  insanity,  though  the  physician  may  never  have 
visited  the  asylum  to  which  he  has  been  made  consultant  by  courtesy, 
and  tliough  the  coroner's  assistant  has  been  created  by  purely  political 
influence,  with  no  regard  to  his  attainments  as  a  pathologist.  An  evil 
of  this  kind  has  perhaps  no  remedy  save  in  the  elevation  of  the  ideals 
and  standards  of  the  whole  body  of  medical  practitioners.  Its  correc- 
tion can  be  made  by  physicians  alone  or  in  cooperation  with  meml^ers 
of  the  legal  profession,  who  can,  in  their  choice  of  experts,  select  only 
such  as  are  known  to  be  of  high  reputation  for  honor  and  integrity.  In 
some  countries,  as  in  Germany  and  France,  there  is  a  list  of  officially 
appointed  experts  in  various  branches  of  medical  science  from  which 
the  court  may  choose  at  its  pleasure,  but  in  this  country  no  such  list  of 
specialists  exists,  and,  indeed,  there  would  be  great  difficulty  in  the 
selection  and  a]>pointment  of  a  body  of  experts,  since  there  would  be 
no  means  to  determine  the  choice  without  political  or  social  influence. 
It  is  ])ossible  that  a  committee  of  unbiased  physicians  appointed  troni  a 
reputable  medical  society  could  establish  a  list  of  specialists  qualified 
for  court  duties,  but  there  are  many  medical  societies  in  the  regular 
profession,  and  there  are  several  schools  of  medicine  outside  of  the 
regular  school  which  are  legally  recognized,  so  that  a  harmonious 
choice  in  the  interests  of  righteousness  and  justice  would  be  at  present 
quite  unattainable. 


EXPERT    EVIDENCE.  19 

Anotlior  evil  consists  in  tlie  employment  of  experts  by  cmcIi  ]>arty 
te  the  leti'al  controversy,  so  tliat  tlie  experts  are  in  a  manner  opjxised  to 
eacli  otlier,  and  however  nnjM-ejndiced  niav  ])e  his  intention,  there  nnist 
be  often  an  nnconscions  tendency  on  tlie  part  of  the  witness  to  be  biased 
toward  the  side  that  has  secured  and  pays  for  his  services,  a  certain 
infirmity  innate  in  human  mind  and  character.  Tliis  evil  is  overcome 
in  French  laM'  by  the  court  orderintr  an  investigation  by  experts,  either 
seh^cted  conjointly  bv  the  contending  parties  or  a])pointed  bv  the  court 
itself.  The  method  in  Gi'rmany  is  similar.  In  either  country  the 
coiu't  may  be  guided  by  the  expert  opinion  signed  and  submitted  to  it, 
or  may  order  a  new  investigation,  or,  finally,  may  not  feel  constrained 
to  be  bound  by  such  opinion  if  opposed  to  the  judge's  own  convictions. 
The  reason  that  our  system  has  not  long  ago  been  altered  to  meet  the 
needs  of  justice  lies  in  the  chief  characteristic  of  the  American  method 
of  criminal  trial — viz.,  that  the  accused  shall  be  allowed  to  produce  anv 
})roper  legal  or  medicolegal  evidence  in  his  own  favor ;  that  the  judge 
alone  is  judge  of  the  law,  and  the  jury  alone  the  arbiter  of  the  facts.^ 
In  England  the  court  procedure  in  the  matter  of  experts  is  quite 
identical  with  that  of  the  United  States.  It  has  been  suggested — and 
the  system  is  in  actual  use  in  some  parts  of  England — that  the  reproach 
which  at  present  attaches  to  expert  testimony  might  be  remedied  by 
the  medical  witnesses  themselves,  in  refusing  to  testify  until  after  con- 
ference with  experts  of  the  other  side.  In  time  these  defects  of  our 
system  must  be  obviated,  for  as  matters  now  are  many  judges  express 
themselves  as  unimpressed  by  experts,  juries  discredit  them,  the  cx])erts 
themselves  chafe  under  the  stigma  attached  to  their  testimony,  and 
justice  all  too  frequently  miscarries. 

The  medical  man  who  is  summoned  as  a  witness  in  a  trial  should  be 
guided  by  a  few  simple  rules  of  conduct,  which  may  be  briefly  sum- 
marized as  follows  : 

1.  In  all  causes  in  which  your  opinion  is  asked  it  is  well  to  arrange 
with  your  client  for  a  proper  fee  for  an  investigation  of  the  case  and  for 
your  opinion  on  the  facts  he  may  set  before  you,  with  the  express  under- 
standing that  you  are  not  to  undertake  to  be  a  witness  should  you  not 
be  wholly  satisfied  as  to  the  merits  of  the  case. 

2.  Before  going  on  the  witness-stand,  make  yourself  thoroughly 
familiar  with  all  the  facts  upon  which  you  are  to  testify. 

■  3.  After  acquainting  yourself  with  all  the  facts  bearing  upon  the 
case  and  carefully  considering  the  opinions  you  would  deduce  from 
them,  it  is  well  to  refresh  your  memory  by  reference  to  the  views  held 
by  standard  writers  in  relation  to  the  subject  in  hand. 

4.  Have  a  conference,  if  possible,  M'ith  the  experts  of  the  other  side 
for  the  purpose  of  interchanging  views. 

5.  Refuse  to  give  evidence  as  an  expert  if  you  have  the  least 
doubt  as  to  the  correctness  of  your  opinion  founded  upon  the  facts 
adduced. 

^  In  Illinois,  Indiana,  INtarvland,  and  a  lew  other  states  the  jury  is  judge  of  hoth 
the  law  and  the  facts  in  criminal  cases. 


20  INTEODITCTION. 

6.  On  the  witness-stand  let  your  bearing:  be  dignified  and  grave ; 
remember  that  the  conviction  or  acqnittal  of  a  human  being  n^ay  hang 
upon  your  testimony,  and  avoid,  therefore,  any  flippancy  of  manner. 

7.  In  testifying  use  plain  and  simple  language,  avoiding  technical 
medical  and  scientific  terms  wherever  possible.  Common  Auglo-Saxon 
terminology  appeals  best  to  the  average  juryman, 

8.  Having  all  your  facts  and  opinions  systematically  arranged  before- 
hand in  your  juind,  be  explicit  and  definite  as  to  these,  and  especially 
as  to  dates,  distances,  sizes,  weights,  and  all  other  measurements. 

9.  Remember  that  your  answers  to  questions  are  taken  down, 
recorded,  and  often  printed,  and  that  the  evidence  you  give  this  day 
may  be  reinvestigated  at  a  subsequent  trial,  and  your  opinions  in  this 
case  brought  before  you  in  some  other  issue,  so  that  you  should  clearly 
understand  each  question  put  to  you,  and  answer  it  deliberately,  care- 
fully, and  coherently. 

10.  Answer  directly  and  simply  the  question  which  is  asked,  volun- 
teering nothing  beyond  what  is  required  to  place  the  facts  or  opinion 
requested  clearly  before  the  court.  You  will  sometimes  be  asked  in 
cross-examination  to  answer  a  question  by  "  yes "  or  "  no "  only,  and 
in  case  such  monosyllabic  replies  are  not  misleading,  you  should  answer 
in  this  way ;  but  if,  as  is  often  the  case,  they  give  but  a  part  of  the 
truth,  it  is  your  duty  to  explain  this  fact  to  the  court  and  request  the 
privilege  of  modifying  the  "  yes "  or  "  no "  so  that  it  may  entirely 
represent  your  views. 

11.  It  is  sometimes  difficult  for  a  witness  to  avoid  the  unconscious 
bias  which  makes  him  involuntarily  hesitate  to  answer  directly  a  ques- 
tion when  he  sees  it  may  do  harm  to  the  side  that  employs  him  ;  but 
you  are  there  "  to  tell  the  truth,  the  whole  truth,  and  nothing  but  the 
truth,"  whether  it  is  good  or  bad  for  one  party  or  the  other,  and  your 
straight  unbiased  answer  to  every  question  of  examiner  or  cross-exam- 
iner will  do  much  to  dignify  your  testimony  and  to  impress  the  jury 
with  the  sincerity  and  value  of  your  statements.  Never  answer  in  such 
a  manner  as  to  allow  even  a  remote  suspicion  that  you  are  a  partisan. 
On  the  other  hand,  however,  in  your  desire  to  be  perfectly  fair  do  not 
permit  the  cross-examiner  to  obtain  from  you  statements  which  directly 
or  indirectly  may  be  distorted  in  their  application  and  lead  to  unfair 
inferences. 

12.  The  cross-examiner  may  attempt  to  irritate  you  by  his  manner 
or  by  the  character  of  his  questions.  It  is  almost  needless  to  say  that 
when  he  does  this,  he  considers  it  a  part  of  his  duty  to  his  client.  He 
will  usually  resort  to  any  legitimate  means  to  minimize  the  value  of 
your  testimony,  and  will  sometimes  use  even  questionable  methods  to 
accomplish  this.  Be  carefnl,  clear,  honest,  and  take  no  offense.  You 
will  then  deprive  him  of  one  of  his  weapons.  He  may  intentionally  or 
by  mistake  mislead  you  through  misquotation  or  misrepresentation  of  an 
author  or  by  the  exhibition  of  diagrams.  Verify  the  quotations  and 
the  diagrams  before  answering  questions  connected  with  them, 

13.  You  may  be  asked  if  the  work  of  such  and  such  a  writer  is  an 


EXPERT    EVIDENCE.  21 

authority,  and  upon  assenting  to  this,  quotations  maybe  cited  in  oppo- 
sition to  the  facts  you  may  have  given,  lacing  sure  of  your  facts,  do 
not  allow  your  judgment  to  be  shaken,  however  great  the  reputatimi  of 
the  authority,  for  even  the  authors  of  books  are  mistaken  sometiujcs. 
If  you  desire  (piotations  from  authorities  to  substantiate  your  state- 
ments, you  can  arrange  with  the  lawyer  engaging  you  to  lav  such 
relevant  matter  before  the  jury  either  through  yourself  or  other  expert 
witnesses. 

14.  The  law  permits  yoti  to  refresh  your  memory  as  to  facts,  dates, 
dimensions,  etc.,  by  reference  to  your  original  notes,  but  you  may  not 
read  your  notes  to  the  court. 

15.  It  is  well  methodically  to  separate  in  your  mind  the  facts  which 
you  have  to  present  from  the  o])inions  you  deduct  from  them  or  deduce 
from  the  evidence  oti'ered  to  you. 

The  lawyer,  from  his  education  in  legal  matters  and  from  his 
experience  in  court  procedures,  naturally  is  much  better  informed  than 
the  average  physician  in  regard  to  the  best  course  to  pursue  in  preparing 
expert  evidence  and  in  presenting  it  to  the  court  and  jury.  In  sj)ite 
of  this,  however,  the  attorney  sometimes  falls  into  bad  methods  and 
indulges  in  practices  that  are  harmful  to  himself  professionally  and  to 
his  client  practically,  and  we  believe  that  not  infrequently  he  is  quite 
as  open  to  criticism  as  is  the  medical  witness.  In  the  same  manner, 
therefore,  as  we  have  given  advice  above  to  the  physician  when  called 
to  the  witness-stand,  we  would  ]iresent  to  the  advocate  the  following 
suggestions  for  his  guidance  in  dealing  with  expert  medical  testimony  : 

1.  In  selecting  experts  engage  only  those  whose  efficiency  and  hon- 
esty are  absolutely  above  the  slightest  suspicion.  The  desire  to  win 
a  legal  victory  for  one's  client  should  never  tempt  the  attorney  to  de- 
part from  this  rule.  Not  only  is  it  the  honest  way,  hnt  in  the  end  it  is 
the  best  way.  An  ignorant  or  dishonest  expert  will  almost  invariably 
be  exposed  eventually  and  bring  discomfiture  to  the  cause  for  which  he 
has  testified.  The  disrepute  into  which  expert  testimony  has  fallen  is 
due  quite  as  much  to  the  legal  profession  as  to  the  medical,  and  were 
attorneys  to  refuse  in  all  cases  to  engage  any  but  jierfectly  competent 
and  honoral)le  experts,  the  opprobrium  that  has  come  upon  it  would 
soon  be  removed. 

2.  Before  entering  upon  the  trial  of  a  case  the  attorney  should  have 
a  complete  consultation  with  his  expert  witness  or  with  all  of  them,  if 
more  than  one  is  engaged,  and  this  should  be  done  preferably  when  all 
are  assembled.  The  attorney  should  know  in  advance  exactly  what 
facts,  theories,  deductions,  and  opinions  the  witnesses  will  testify  to,  and 
if  more  than  one  witness  is  engaged,  an  exchange  of  views  between  them 
in  the  presence  of  the  attorney  will  more  fully  enlighten  the  latter  and 
will  also  serve  to  correct  erroneous  views  which  may  by  chance  be  held 
by  some  of  the  experts  themselves.  A  fiiilure  thus  to  become  com- 
pletely familiar  with  the  views  of  the  expert  witness  has  in  more  than 
one  case  with  which  we  are  acquainted  been  the  cause  of  a  miscarriage 
of  justice. 


22  INTRODUCTION. 

3.  It  is  obviously  beyond  the  power  of  any  attorney,  no  matter  how 
well  informed,  to  make  himself,  unaided,  entirely  familiar  with  the  sub- 
jects presenting  themselves  during  the  trial  of  any  except  the  simplest 
medicolegal  cases.  It  is  advisable,  therefore,  that  a  thoroughly  in- 
formed expert  of  quick  intellect  be  engaged  by  the  attorney  to  help 
him  in  the  preparation  of  the  case  and  to  sit  at  his  side  during  the  trial 
to  aid  him  in  preparing  questions,  especially  during  the  cross-examin- 
ation. It  is  inadvisable,  however,  that  such  expert  be  afterward  called 
to  the  witness-stand  on  account  of  the  bad  moral  effect  on  the  jury. 
Thoroughly  honest  and  honorable  though  he  may  be,  and  perfectly 
legitimate  as  his  association  with  the  attorney  has  been,  the  impression 
is  liable  to  be  conveyed  to  the  jury  that  he  is  a  semi-advocate,  and 
his  testimony,  however  unprejudiced  it  may  be  in  reality,  is  likely  to  be 
accepted  with  doubt,  and  may  inferentially  throw  discredit  upon  the 
testimony  of  other  witnesses. 

4.  In  the  cross-examination  of  an  expert  witness,  the  cultivated  and 
wise  attornev  will  not  resort  to  brow-beating;  or  harsh  or  deceitful 
methods  unless  he  is  positively  convinced  of  the  dishonesty  of  the  wit- 
ness, Avhen  such  methods  may  sometimes  be  required.  With  an  expert, 
how^ever,  of  honesty  and  capability,  nothing  is  so  likely  to  lead  him 
into  partisan  ways  and  the  making  of  emphatic  statements  as  harsh  or 
ungentlemanly  treatment  at  the  hands  of  his  examiner.  As  a  mere 
matter  of  policy,  therefore,  laying  aside  more  ethical  reasons,  the  at- 
torney does  well  to  avoid  such  methods. 


THE  TECHNIC  OF  MEDICOLEGAL  POST- 
MORTEM EXAMINATION. 


INTRODUCTION. 


A  POSTMORTEM  examination  for  medicolegal  purposes  is  generally 
made  in  order  to  determine,  as  far  as  possible  in  the  power  of  medical 
science,  the  cause  and  the  kind  of  death.  In  order  that  all  the  information 
bearing  upon  this  problem  which  can  be  gathered  from  the  examination 
of  a  dead  body  may  be  obtained,  it  is  essential  that  the  examination  be 
made  in  a  thorough  and  exhaustive  manner,  by  competent  persons  ; 
and  that  the  results  of  the  observations  be  made  more  or  less  permanent 
by  being  recorded  ]>roperly.  It  is  not  sufficient  sunply  to  demonstrate 
the  existence  of  a  fatal  lesion,  because  all  other  possibly  fatal  lesions  of 
the  organs  of  a  body  must  be  shown,  by  actual  examination,  to  be 
absent  before  any  existing  lesion  can  be  concluded  to  be  the  sole  cause 
of  death.  If  various  lesions  coexist,  the  possible  interdependence  of 
these  lesions  and  the  relations  of  each  to  the  causation  of  death  must  be 
determined  and  made  clear  to  the  administrators  of  the  law.  Hence  a 
postmortem  examination  for  legal  purposes  must,  if  the  conclusions 
based  upon  its  results  are  to  stand  the  test  of  scientific  and  judicial 
scrutiny,  include  a  trustworthy  investigation  of  practically  all  the 
organs  and  structures  of  the  body. 

Accurate  observations,  completeness,  and  correct  conclusions  are 
obtainable  only  when  the  postmortem  examination  is  made  according  to 
a  definite  or  systematic  plan,  by  means  of  which  regions  and  organs  are 
successively  examined  \\ith()ut  disturbing  the  relations  and  appearances 
of  those  being  or  yet  to  be  examined.  In  order  to  obtain  the  im])roved 
results  thus  attainable,  many  governments  prescribe  by  rules  and  regu- 
lations the  exact  order  and  steps  to  be  followed  in  medicolegal  exam- 
inations. When  such  matters  are  left  in  the  hands  of  the  individual 
physician,  it  is  believed  that  the  following  directions  will  atlbrd  material 
aid  in  reachinir  the  desired  result. 


'» 


INSTRUMENTS  AND  UTENSILS. 

The  following  instruments  and  appliances  are  essential  for  the  proper 
postmortem  examination  of  medicolegal  cases  : 

Knives. — The  lons^  incisions  and  the  coarse  dissection  are  made 
witli  a  so-called  section  knife.  This  knife  should  possess  a  deep  bellied 
blade,  about  2  cm.  (0.79  inch)  broad  and  11  cm.  (4.33  inches)  long, 
with    a    heavy,  preferably  wooden,  handle,  about    2    cm.   (0.79    inch) 

23 


24      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

thick  and  12  or  13  cm.  (4.72  to  5.11  inches)  long,  and  modeled  so 
that  it  can  be  firmly  grasped  with  the  whole  hand. 

The  more  minute  dissection  requires  ordinary  scalpels. 

The  brain  knife  is  a  very  useful  and  important  instrument,  employed 
for  incising  the  organs  so  that  they  present  smooth  and  extensive  cut 
surfaces,  upon  which  the  structural  conditions  may  be  studied.  The 
most  universally  convenient  form  of  the  brain  knife  is  like  an  amputa- 
tion knife;  it  should  have  a  total  length  of  about  30  cm.  (12  in.), 
equally  divided  between  the  blade  and  the  handle ;  the  blade  should  be 
about  1.8  cm.  (0.7  in.)  broad,  and  so  strong  that  it  does  not  bend  or 
feather  too  easily.  The  thin,  double-edged  brain  knife  with  the  rounded 
end  is  more  especially  serviceable  in  incising  the  brain. 

The  myelotome  (Pick)  is  a  small  knife  used  in  removing  the  brain 
by  dividing  the  medulla  from  the  spinal  cord  in  such  a  manner  as  to 
secure  exactly  transverse,  and  not  oblique,  cut  surfaces.  It  consists  of 
a  blade  1.5  cm.  (0.59  in.)  long  and  4  mm.  (0.16  in.)  broad,  and  rounded 
at  the  extremity.  This  blade  is  attached  to  a  stem  at  an  angle  of 
about  100  degrees,  the  stem,  with  its  wooden  handle,  being  about  24 
cm.  (9.5  in.)  long. 

Scissors. — Anatomic  scissors  with  one  blunt  and  one  sharp  blade 
are    necessary.       Probe-pointed    scissors    are   very   useful    for    incising 


Fig.  1.— Single-bladed  saw,  with  rounded  blade,  30  cm.  (12  in.)  long  and  10  cm.  (4  in.)  broad  at 
the  broadest  part,  for  removing  vertebral  arches. 

vessels  and  canals  of  various  kinds.  The  enterotome,  or  intestinal 
scissors,  has  one  of  the  blades  provided  with  a  blunt,  projecting 
extremity,  whicli  should  be  perfectly  smooth  and  free  from  sharp  points 
or  edges  that  might  catch  in  the  folds  of  the  mucous  membrane  of  the 
intestines  or  the  columnse  carnese  of  the  heart.  A  convenient  size  has 
blades  about  9  cm.  (3.5  in.)  long,  and  the  blunt  projection  is  about  8  mm. 
(0.31  in.)  long,  6  mm.  (0.24  im)  broad,  and  4  mm.  (0.16  in.)  thick.  In 
use,  the  blade  with  the  blunt  projection  is  always  lowermost.  Stronger 
bone  scissors  are  useful  for  cutting  the  laryngeal  cartilages,  the  ribs,  etc. 

Dissecting  Forceps. — Two  pairs,  one  strong  and  large,  one 
small  and  delicate,  are  required. 

Probes,  large  and  small,  of  metal  or  bone,  a  grooved  director, 
and  a  catheter,  are  necessary. 

Saws. — A  })utcher's  saw  will  answer  the  purpose  very  well.  A 
bone-saw  with  a  movable  back  and  detachable  blade,  with  not  too 
fine  teeth  and  well  set,  is  preferable.     For  the  purpose  of  removing 


INSTRUMENTS    AND    UTENSILS.  25 

parts  from  the  base  of  the  skull  a  keyhole  saw  may  be  desirable,  and 
in  order  to  divide  long  bones  in  a  lonixitudinal  direction  a  l)and  saw  is 
almost  necessary. 

For  sawing  the  laminae  of  the  spinal  cohunn  a  saw  with  a  (-urved 
handle  and  rounded  broad  blade,  10  cm.  (4  in.)  broad  at  the  broadest 
])art  and  30  cm.  (12  in.)  long  (Fig.  1),  is  very  useful  ;  or  a  more 
expensive  double  saw  with  moval)le  blades,  known  as  liner's  rachio- 
tome,  may  be  used.  A  strong  bone-ibrceps  is  useful  in  removing  the 
arches  after  sawing  the  lamina?. 

Chisels. — A  chisel  with  a  straight  edge  and  a  strong  Avooden  handle, 
the  blade  being  about  3  cm.  (1.18  in.)  broad,  will  answer.  A  T-shaped 
steel  chisel  with  a  blade  about  G  cm.  (2.36  in.)  long,  1.8  cm.  (0.7  in.) 
broad,  and  6  mm.  (0.24  in.)  thick,  attached  at  right  angles  to  the  center 
of  a  steel  handle  9  cm.  (3.5  in.)  long  and  about  1  cm.  (0.39  in.)  thick, 
is  used  to  loosen  the  calvaria  from  the  pachymeninx.  A  heavy  wooden 
or  rawhide  mallet  or  an  ordinary  steel  hammer  is  also  required. 

I^inear  and  I<iquid  Measures. — A  brass  or  w<3oden  foot-rule, 
graduated  into  inches  and  ('cntimeters,  is  necessarv  ;  also  a  steel  or  cloth 
tape-measure.  Caliper  compasses,  with  a  graduated  cross-bar,  are 
handy.  Graduated  cups  or  glasses  for  measuring  the  quantity  of  liquids 
and  for  volumetric  measurement  of  solid  bodies  by  re})lacement  of 
water  are  necessary.  Every  set  of  postmortem  instruments  should 
include  some  kind  of  measure  of  known  and  exact  capacity. 

Scales. — Weighing  determines  actual  increase  or  decrease  on  part 
of  an  organ  more  accurately  than  measurement.  In  larg-e  dead-houses 
scales  should  be  arranged  for  the  weighing  of  the  whole  cadaver ;  a 
fulcrum  and  lever  arrangement  underneath  the  postmortem  table  would 
weigh  the  body  as  it  is  placed  in  position  for  the  autopsy.  Scales 
capable  of  weighing  up  to  3000  or  4000  grams  (8  to  10  pounds),  with 
suitably  subdivided  weights,  are  necessary  in  order  to  weigh  the  organs. 
When  the  examination  is  made  in  a  private  house,  it  may  be  difficult 
or  out  of  the  question  to  secure  the  weights  of  the  organs  of  the 
body. 

Among  other  instruments  necessary  may  be  mentioned  postmortem 
needles  and  thread  (Barbour's  linen  thread.  No.  25,  is  sufficiently  strong). 
Sponges,  pails,  vessels,  plates,  and  bottles  are  articles  found  in  all  post^ 
mortem  rooms ;  when  the  examination  is  made  in  a  ])rivate  house,  it  is 
well  to  come  provided  with  the  necessarv  si^ongcs  and  bottles. 

Histologic,  Chemical,  and  Bacteriologic  Utensils. — At 
the  present  time  the  satisfactory  examination  of  the  dead  body  very  fre- 
quently requires  microscopic,  bacteriologic,  and  chemical  investigation 
of  the  tissues  and  fluids,  and  in  many  cases  the  autojisy  is  in  reality 
only  the  first  step  in  the  study  of  the  case.  Inasmuch  as  the  ultimate 
result  depends  u]>on  the  work  being  comjilete  and  correct  from  the 
beginning,  it  may  be  necessary  for  the  examiner  in  j)rivate  cases,  in  the 
country  or  removed  from  the  conveniences  of  a  fully  e(pii})])ed  postmortem 
room,  to  bring  with  him  suitable  fixing  solutions  for  histologic  purposes, 
glass-stoppered  jars   for  receipt  of    the   organs  in  cases  of  poisoning, 


26      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

suspected  or  otherwise,  and  utensils  for  securing,  during  the  course  of 
the  autopsy,  proper  material  for  subsequent  bacteriologic  examination. 

For  detailed  information  concerning  the  solutions  necessary  to  pre- 
serve material  for  histologic  study,  and  for  directions  how  to  secure 
material  for  bacteriologic  purposes,  reference  is  made  to  the  works  on 
histologic  and  bacteriologic  technic. 

THE  RECORD. 

It  is  essential  that  the  observations  made  during  a  postmortem 
examination  be  carefully  recorded  at  the  time,  and  in  such  a  manner 
that  the  notes  can  be  used  for  reference  on  the  witness-stand.  In  this 
record  should  be  described,  as  completely,  accurately,  and  objectively  as 
possible,  that  which  is  actually  observed ;  the  description  should  be 
concise,  clear,  and  unembellished,  and  should  not  include  deductions  or 
opinions  except  under  the  head  of  conclusions  or  diagnosis.  If  the 
record  is  dictated  during  the  course  of  the  examination,  it  should  be 
verified  carefully  by  the  examiner  when  it  is  finished. 

The  record  should  be  made  in  the  same  order  as  the  examination, 
and  for  this  reason  each  step  in  the  autopsy  should  be  completed,  if 
possible,  before  the  next  is  commenced.  The  record  consequently 
embodies  the  fi)llowing  subdivisions  : 

1.  Preliminary  data,  including  name,  sex,  age,  color,  time  and 
place  of  death  and  examination,  the  names  of  the  persons  present,  and, 
invariably,  of  those  by  whom  the  body  is  identified.  If  positive 
identification  by  some  one  who  knew  the  dead  person  during  life  is  not 
obtainable,  a  detailed  description  of  the  characteristics  of  the  body  must 
be  taken  down  under  the  heading  of  inspection. 

2.  Summary  of  the  Clinical  History. — Clinical  information 
should  be  obtained,  when  possible,  from  the  medical  attendant,  the 
friends,  the  police,  or  the  hospital  records,  so  that  the  postmortem 
examination  may  be  made  as  intelligently  as  this  knowledge  makes  it 
practicable. 

3.  Inspection. — Under  this  heading  are  included  complete  notes 
as  to  the  size,  the  development,  the  nutrition,  the  rigor  mortis,  the 
livores  mortis,  and  the  evidences  of  decomposition  that  may  be  present. 
All  marks  of  violence  must  be  carefully  described,  with  detailed  minute- 
ness as  to  location  with  reference  to  fixed  anatomic  landmarks,  size, 
shape,  color,  etc.  If  the  body  is  that  of  an  unknown  person,  the 
necessary  descriptive  details  must  be  ascertained  and  carefully  recorded. 

4.  Internal  Bxamination.  —  The  record  should  contain  a 
detailed  objective  account  of  the  appearances  observed  in  the  cavities 
and  organs  of  the  body.  The  size  and  weight  of  the  organs,  the  size 
of  abnormal  areas  and  growths,  should  be  inserted  in  actual  figures  as 
often  as  possible,  rather  than  in  relative  measurements. 

5.  Diagnosis  or  Conclusions. — Here  are  enumerated,  in  the 
most  natural  order,  the  various  anatomic  clianges  observed.  In  case 
the  record  is  sent  as  a  whole  to  some  court  or  corporation,  the  summary 


EXAMINATION'    OF    TIIK    I50DV.  27 

should  contain,  in  clear  and  concise  terms,  the  conclusions  as  reg;ards 
the  cause  and  manner  ot"  death,  formed  hy  the  physician  from  the 
examination  recorcleih 

In  the  variety  of  medicoleiial  cases  known  as  coroner's  cases,  the 
statement  wanted  from  the  physician  who  makes  the  autopsy  is  one  that 
clearly  and  concisely  describes  the  cause  of  death,  because  this  is  deter- 
mined by  a  jury  of  laymen,  and  the  rei)ort  should  be  so  worded  that  a 
fairly  intelligent  layman  can  readily  grasp  its  import ;  but  it  need  not 
always  include  the  many  and  otiicrwisc  important  details  that  are  found 
in  the  complete  record  made  for  future  reference — as,  for  instance, 
during  a  criminal  trial. 

EXAMINATION  OF  THE  BODY. 

The  general  arrangements  of  the  postmortem  room  of  the  modern 
hospital  do  not  require  any  detailed  description.  Unobstructed  dayligiit 
is  essential  for  correct  interpretation  of  colors,  and  a  medicolegal  exam- 
ination, comjileted  for  especially  urgent  reasons  by  artificial  light,  may 
be  open  to  criticism,  and  the  observations  should,  under  such  circum- 
stances, always  be  controlled  by  microscopic  examination,  more  particu- 
larly when  it  concerns  diiFuse  lesions  of  the  parenchymatous  organs. 

In  a  private  house  the  available  room  with  the  best  light  and  the 
least  furniture  should  be  selected  in  which  to  hold  the  autopsy.  The 
bodv  mav  be  placed  on  a  kitchen  table  or  left  Ivino;  on  the  undertaker's 
stretcher ;  it  is  advisable  to  protect  the  floor  around  the  body  by 
means  of  oilcloths  or  old  quilts.  Abundant  provisions,  in  the  form 
of  pails,  basins,  pitchers,  and  warm  and  cold  water,  must  be  made  for 
cleanliness,  towels  and  sponges  should  be  at  hand,  and  trays  or  plates 
on  which  to  place  the  organs  are  also  necessary. 

The  hands  and  the  instruments  should  be  washed  frequently  during 
the  course  of  the  examination  ;  blood  and  inflammatory  exudate  dried 
on  the  fingers  are  unpleasant  and  dull  tlie  sensitiveness  of  the  skin. 
The  knives  should  be  clean  when  the  org-ans  are  incised. 

In  the  hospital  postmortem  room  water  may  be  allowed  to  run  over 
the  body  at  frequent  intervals,  but  its  liberal  use  must  not  in  any  way 
obscure  the  condition  of  the  body  cavities  or  their  contents.  AYater 
must  not  be  allowed  to  come  in  contact  with  the  spinal  cord  or  the 
brain  in  case  these  structures  are  to  l)e  liardened  in   Miiller's  fluid. 

The  body  to  be  examined  is  placed  upon  the  table  in  the  supine 
position,  and  all  clothing,  including  the  stockings,  is  removed.  Under 
all  circumstances  the  examination  of  the  exterior  of  the  body  is 
invariably  first  in   order. 

INSPECTION. 

The  external  examination  or  inspection  of  a  dead  body  determines 
not  only  the  general  physical  characteristics  of  the  body,  but  also  the 
condition  of  the  skin,  the  subcutaneous  tissue,  the  nnicous  membranes, 
the  accessible  canals  and  cavities,  as  well  as  of  the  superficial  organs, 
such  as  the  eye,  as  regards  morbid  changes  or  wounds.     In  the  case  of 


28      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

unknown  bodies  the  inspection  aims  to  furnish  such  positive  data  con- 
cerning the  physical  appearance  as  may  form  the  basis  for  a  definite 
identification. 

Inspection  falls  into  two  parts  :  a  general,  in  which  the  general 
external  conditions  are  studied ;  and  a  special,  in  which  the  particular 
external  conditions  of  the  individual  parts  of  the  body  are  examined. 

General  inspection  determines  the  height,  sex,  approximate  age, 
color  and  state  of  the  skin  in  general,  stature,  state  of  general 
nutrition,  and  the  degree  and  nature  of  the  postmortem  changes 
present.  Whenever  possible,  the  exact  weight  of  the  body  should 
be  determined. 

The  body  length  is  measured  by  means  of  a  tape  or  anthropologic 
measure  placed  upon  the  table  by  the  side  of  the  cadaver  ;  the  distance 
determined  is  that  between  the  highest  point  of  the  head  and  the  center 
of  the  sole  of  the  heel. 

The  color  is  usually  determined  by  a  glance,  but  inveterate  filth,  coal- 
dust,  etc.,  may  make  it  difficult  to  establish  the  exact  shade  of  the  normal 
color  of  the  skin  ;  in  such  cases  the  surface  must  be  cleansed  well. 

The  skin  in  general  may  contain  varying  amounts  of  blood  ;  its 
tension  and  elasticity  may  be  tested  by  raising  it  into  folds ;  diffuse 
eruptions,   pigmentations,  and  edema  are  noted. 

The  stature  may  be  large  and  powerful,  or  smaller,  finer,  and 
delicate ;  evident  disproportions  between  the  various  parts  of  the 
skeleton  may  exist. 

The  state  of  the  general  nutrition  is  shown  by  the  fulness  and 
roundness  of  the  form  and  the  quantity  of  subcutaneous  adipose  tissue. 

The  degree  of  rigor  mortis  present  is  determined ;  it  is  to  be 
remembered  that  cadaveric  rigidity  first  shows  itself  about  the  muscles 
of  the  lower  jaw,  from  which  it  gradually  extends  downward ;  it  dis- 
appears in  the  same  sequence. 

The  livores  mortis,  or  postmortem  lividities,  are  of  normal  post- 
mortem occurrence.  They  are  reddish  or  livid  discolorations  appearing 
upon  the  undermost  parts  of  the  body  that  are  not  subjected  to  pressure, 
and  are  due  to  the  simple  gravitation  of  the  intravascular  blood.  Dif- 
fusion of  the  blood  coloring-matter  into  the  perivascular  tissue  may 
occur  when  decomposition  begins. 

Decomposition  shows  itself  first  as  greenish  discolorations  in  those 
regions  where  the  viscera  are  nearest  the  surface,  as  in  the  lateral  and 
inguinal  parts  of  the  abdomen.  Advanced  decomposition  produces 
extensive  discolorations ;  the  tissues  become  infiltrated  with  fluids  and 
gases ;  by  accurate  observation  of  the  extent  of  the  changes,  the  cir- 
cumstances, etc.,  an  approximate  idea  may  be  formed  as  to  the  length 
of  time  that  has  elapsed  since  death. 

In  medicolegal  autopsies  the  nature  of  all  areas  of  discoloration 
upon  the  dead  body  must  be  definitely  settled,  and  the  following  are 
some  of  the  more  important  points  to  consider  : 

Their  location,  size,  and  shape ;  the  effects  of  pressure  in  removing 
the  color ;  the  exact  shades  of  color  observed  ;  the  absence  or  presence 


EXAMINATION    OF    THE    BODY.  29 

of  tension  or  elevation  over  the  area  ;  and,  linally,  the  condition  of  tlie 
underlying  tissue  as  regards  infiltration  with  iiuid  or  clotted  blood. 
None  of  the  usual  and  early  ])()stinorteui  discolorations  is  accompanied  by 
swellings,  but  extravasations  usually  are.  The  postmortem  hypostasis 
stain  can  be  removed  for  a  moment  by  pressure,  and  does  not,  on  inci- 
sion, show  any  Irec  l»lood  in  the  tissues  outside  of  the  vessels.  Extra- 
vasations due  to  violence  or  other  causes  present  areas  iu  which  the 
tissue,  on  incision,  is  found  infiltrated  with  free  fluid  or  clotted  blood, 
due  to  the  rupture  of  the  blood-vessels.  Extravasations  ])roduced 
immediately  after  death  cannot,  under  some  circumstances,  be  distin- 
guished from  autemortem  infiltrations,  and  decomposition  may  so  change 
appearances  that  a  correct  interpretiition  may  become  very  difiicult. 

Inspection  of  the  exterior  of  the  individual  parts  of  the  body  must 
be  minute  and  systematic,  and  should  take  up  the  various  regions  in  the 
folli ) wing  order  : 

The  Head. — Peculiarities  of  formation  are  to  be  noted.  The 
quantity,  length,  and  color  of  the  hair  and  tlie  l)eard ;  the  condition  of 
the  scalp  as  regards  wounds  and  scars ;  the  eyelids,  eyeballs,  and 
pupils;  the  state  of  the  nose,  mouth,  and  ears  as  regards  foreign  Ixxlics, 
blood,  and  other  fluids  ;  the  color  of  the  lips  and  the  nose  ;  the  teeth,  the 
tongue — these  are  some  of  the  more  important  structures  and  points  to 
be  investigated. 

The  Neck. — The  leno-th  and  thickness  of  the  neck  are  to  be 
noticed,  and  it  must  be  closely  examined  for  livid  spots  and  marks  of 
violence,  as  well  as  for  glandular  enlargements,  etc. 

The  Chest. — Here  are  to  be  noted  in  general  the  dimensions, 
possible  as}Tnmetries,  and  other  deviations  in  form  ;  in  women,  the  ful- 
ness of  the  mammary  glands  and  the  absence  or  presence  of  milk  iu 
them  must  be  studied. 

The  Abdomen. — The  degree  of  abdominal  distention  ;  the  condi- 
tion of  the  inguinal  and  crural  regions  with  reference  to  hernia  ;  the 
presence  of  lineae  albicantise,  of  scars,  and  of  swellings — these  are  some 
of  the  subjects  for  inspection. 

The  ;^xternal  Genitals  and  the  Anus. — In  women  suspected 
of  having  died  from  the  results  of  al)ortion  the  external  genitals  are  to  be 
carefully  examined  for  ruptures  and  tears,  punctures,  and  other  wounds, 
for  foreign  bodies,  inflammatory  lesions,  and  peculiar  discharges.  In 
cases  of  assault,  the  condition  of  the  hymen  and  the  iutroitus  vaginae 
must  be  examined  for  evidences  of  violence ;  and  the  fluids  present,  as 
well  as  the  stains  upon  the  clothing,  must  be  studied  microscopically  for 
spermatozoa.  In  men  the  glans  penis  and  the  jirepuce  are  to  be 
searched  for  syphilitic  and  other  cicatrices.  The  anus  shoidd  also  be 
investigated  for  inflammatory  and  other  changes,  as  well  as  for  foreign 
bodies. 

The  Extremities. — Finally,  the  extremities  are  taken  up  and 
examined  for  defects,  deformities,  edema,  ulcers,  scars,  gouty  deposits, 
articular  changes,  external  injuries,  etc. 

While  the  external  examination  very  often  consists  in  mere  ocular 


30      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

and  palpatory  investigation,  the  examiner  should  never  hesitate  or  delay 
to  incise  areas  that  attract  his  attention.  Later  on  in  tbe  course  of  the 
autopsy  the  surface  may  become  soiled,  or  the  examination  of  such 
places  may  be  neglected. 

All  wounds  must  be  accurately  described  and  located  with  reference 
to  fixed  anatomic  landmarks.  The  dimensions  of  wounds  should  be 
accurately  and  precisely  measured  and  stated  in  dctinite  figures,  and 
not  in  comparative  or  approximate  terms.  Penetrating  wounds  must 
not  be  probed  indiscriminately,  because  of  the  liability  of  rupturing 
the  walls  of  important  cavities  and  of  complicating  the  extent  of  the 
original  wound.  Careful  dissection  should  be  made  to  determine  the 
course  and  direction  of  the  wounds ;  sometimes  this  can  best  be  done 
after  opening  the  cavities  of  the  body,  but  as  a  general  rule  the  external 
examination  should  be  quite  fully  finished  before  the  cavities  are  opened, 
because  thereafter  the  turning  of  the  body  may  be  undesirable  and  the 
anatomic  relations  are  often  quickly  disturbed. 


INSPECTION  IN  THE  CASE  OF  UNKNOWN,  BURNED,  AND 

DECOMPOSED  BODIES. 

The  physical  and  other  peculiarities  of  dead  unknown  persons 
require  the  most  careful  examination  and  record  for  the  purpose  of 
aiding  possible  future  identification.  AVhenever  the  state  of  the  body 
is  such  as  to  warrant  it,  one  or  more  good  photographs  should  be  taken 
of  the  face ;  in  many  cases  different  views  are  desirable.  Under 
all  circumstances,  in  addition  to  the  photographs,  careful  observations 
in  regard  to  the  following  conditions  and  facts  are  to  be  recorded — to 
wit :  Age,  sex,  height,  weight,  build,  forehead,  face,  eyes,  nose,  hair, 
teeth,  beard,  mustache,  complexion,  scars,  marks,  condition  of  fingers 
and  toes,  overcoat,  coat,  vest,  pantaloons,  underwear,  shawl,  cloak, 
dress,  boots,  shoes,  stockings,  necktie,  personal  property,  probable 
occupation  and  reasons  for  determining  it,  etc.,  as  well  as  a  note  of  the 
locality  where  the  body  was  found. 

In  the  case  of  bodies  changed  beyond  ready  recognition  by  the 
destructive  action  of  fire,  the  identification  may  be  favored  by  such 
general  information  as  can  be  obtained  in  regard  to  the  sex,  the  height, 
etc.,  of  the  body  ;  while  certain  conditions  of  the  teeth,  bits  of  clothing, 
finger-rings,  certain  peculiar  deformities,  etc.,  may  determine  the  identity. 

In  the  case  of  greatly  decomposed  bodies,  an  effort  should  first  be 
made,  when  necessary,  to  determine  the  sex  by  finding  perhaps  distinct 
remains  of  the  uterus,  which  is  one  of  the  last  structures  to  undergo 
disintegration  ;  the  condition  of  the  hair,  skeletal  peculiarities,  etc., 
must  not  be  forgotten. 

All  unknown,  decomposed,  and  changed  bodies  shoidd  be  examined 
in  the  general  manner  indicated,  and  physical  ])eculiarities,  such  as 
peculiar  teeth,  hernia,  malformations,  deformities  after  fractures,  etc., 
should  always  ])e  looked  for,  as  they  play  a  prominent  part  in  deter- 
mining the  identity. 


EXAMINATION    OF    THE    BODY.  31 

INSPECTION  OF  THE  SURROUNDINGS  OF  THE  BODY. 

In  medicolegal  eases  the  external  inspection  often  inclndes  an  exam- 
ination of  the  clothing  of  the  body  for  tears,  holes,  stains,  etc.;  and  also 
of  the  premises  where  the  body  was  found.  Particular  attention  is  to 
be  given  to  the  position  of  tiie  body  with  reference  to  the  furniture, 
blood-stains,  vomited  matter,  glasses,  powders,  medicines,  etc.  Stains 
upon  the  carpet,  bed-clothes,  or  personal  clothing  may  have  to  be 
examined.  Instruments  and  other  articles  that  are  to  he  ])reserved 
should  be  placed  under  lock  and  key  for  the  time  being.  Photographs 
of  the  room  or  premises  may  be  valuable. 

FROZEN  BODIES. 

In  case  the  body  be  frozen,  arrangements  must  be  made  for  thawing 
it  out  thoroughly  before  any  internal  examination  is  attempted,  as  many 
organs — the  brain,  for  instance — cannot  be  removed  if  frozen  without 
fatal  damage ;  and  also  l^ecause  the  consistence  of  various  tissues,  the 
absence  or  presence  of  tin'ombosis,  etc.,  cannot  be  made  out  in  struct- 
ures ])artly  or  completely  frozen.  According  to  the  German  regula- 
tions for  guidance  in  conducting  postmortem  examinations  for  legal 
purposes,  the  use  of  warm  water  or  other  warm  substances  for  expedit- 
ing thawing  is  not  allowed. 

EMBALMED  BODIES. 

In  the  case  of  embalmed  bodies  great  care  must  be  exercised  in 
interpreting  the  appearances  observed  in  the  tissues,  as  the  fluids 
employed  are  often  capable  of  greatly  changing  the  consistence  and 
color  of  the  structures  with  which  they  come  in  contact. 

Arterial  embalming  precludes  the  formation  of  any  correct  idea  as 
to  the  blood  distribution  in  the  organs ;  and  in  the  lungs  the  })aren- 
chyma  may  present  a  rough,  shriveled  ajjpearance,  as  though  extensive 
coagulation  had  taken  place. 

In  "  cavity  embalming "  a  long,  coarse  trocar  is  passed  into  the 
abdomen,  and  the  intestines  are  punctured  in  as  many  places  as  ])ossibl(^, 
and  then  penetrations  are  made  in  the  direction  of  the  heart,  great 
blood-vessels,  and  lungs ;  and,  finally,  large  quantities  of  strong  fluid 
are  pumped  in  the  cannula.  Tiie  writer  is  acquainted  with  instances  in 
which  pimctures  of  the  heart  produced  in  this  manner  were  mistaken 
for  spontaneous  ruptures.  Occasionally  a  quantity  of  embalming  fluid 
is  forced  into  the  mouth,  and  small  portions  may  find  their  way  down 
into  the  lungs  and  produce  anomalous  appearances,  quite  jierjilexing  to 
the  uninitiated.  And  it  might  not  be  altogether  impossible  for  some  of 
the  fluid  to  gravitate  into  the  stomach,  to  the  annoyance  and  mystifica- 
tion of  the  toxicologist. 

INTERNAL  EXAMINATION. 

The  Order  of  the  Internal  Examination. — In  medicolegal 
cases  it  is  the  rule  to  direct  attention  first  to  that  part  or  region  of  the 


32      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

body  in  which  there  are  grouuds  to  believe  that  the  cause  of  death  may 
be  found,  and  then  to  examine  the  remaining  cavities  in  whatever  order 
may  be  most  serviceable.  All  postmortem  techuic  is  based  upon  the 
general  rule  that  regions  and  organs  are  to  be  successively  examined 
without  disturbing  the  relations  and  appearances  of  structures  yet  to  be 
investigated  ;  and  w^henever  it  becomes  necessary,  on  account  of  special 
conditions,  to  modify  the  generally  accepted  order  of  procedure,  then 
this  general  rule  should  likewise  govern  the  modification. 

Generally  speaking,  a  complete  medicolegal  postmortem  should  begin 
w'ith  the  head,  and  then  the  spinal  cord  is  best  examined,  especially  in 
case  the  examination  is  made  in  a  private  house.  Turning  the  body 
on  the  anterior  surface  after  having  opened  the  chest  and  abdomen  is, 
under  all  circumstances,  an  uncleanly  operation  ;  but  in  the  hospital 
postmortem  room  the  specially  constructed  tables  in  the  main  remove 
this  objection  to  leaving  the  spinal  cord  until  the  last  if  desired.  Then 
follow  the  long  anterior  incision  and  the  preliminary  inspection  of  the 
cavities  of  the  trunk,  after  which  the  organs  of  the  neck,  thorax,  and 
abdomen  are  examined,  in  the  order  named.  The  order  in  which  the 
single  organs  and  structures  in  these  cavities  are  examined  is  not  of 
essential  importance,  but  the  underlying  principle  should  be  that  organs 
functionally  related  and  anatomically  continuous  are  examined  one  after 
the  other,  and,  if  possible,  without  any  separation  of  continuous  struct- 
ures, until  it  is  shown  that  such  separation  does  not  obscure  morbid 
conditions  or  nuitilate  instructive  specimens.  For  these  reasons  the 
following  technical  description  directs  the  removal  and  examination  of 
each  of  the  respiratory,  digestive,  and  genito-uriuary  tracts  as  far  as 
possible  in  one  continuous  whole. 

In  medicolegal  cases  it  is  best  to  avoid  the  cutting  across  of  large 
vessels  near  the  heart  until  the  relative  amount  of  blood  in  the  heart 
cavities  has  been  determined  ;  and,  consequently,  it  is  recommended  to 
make  an  early  preliminary  examination  of  the  heart  for  this  purpose, 
according  to  the  manner  to  be  described  more  fullv  later  on. 

In  the  case  of  bullet  wounds,  the  common  order  of  procedure  is 
often  violated  in  order  to  trace  definitely  the  course  of  the  bullet,  as 
well  as  to  recover  the  bullet  itself,  if  it  be  present  in  the  body,  because 
of  its  importance  in  the  eyes  of  the  law  as  the  eorpnn  de/icti,  as  well  as 
because  of  the  relation  of  its  size  to  the  caliber  of  firearms  that  may  be 
found  upon  persons  connected  in  some  way  with  the  shooting.  When 
a  bullet  wound  has  produced  extensive  hemorrhage  into  a  large  cavity, 
such  as  the  ]ieritoneal  or  the  pleural  cavity,  the  blood  should  be  first 
completely  removed,  and  the  blood-clots,  as  well  as  the  interior  of  the 
cavity,  examined  for  the  presence  of  the  bullet.  If  the  bullet  is  not 
found  there,  then  its  course  through  the  tissues  must  be  followed  by 
locating  the  various  wounds  produced,  and,  generally  speaking,  no 
organ  should  be  removed  until  it  is  definitely  settled  that  its  removal 
does  not  in  any  way  obscure  the  conditions.  The  best  rule  to  follow 
in  these  cases  is  to  trace  the  bullet  to  its  final  resting-place,  or  as  far  as 
possible  toward  that  point,  before  removing  or  incising  any  organs. 


EXAMINATION    OF    THP:    BODY.  33 

It  should  be  romcmhcrcd  tliat  bullets  euteriu<>:  the  body  al)Out  the 
face  may  be  swalhnved  ;  aud  that  iu  bullet  wouuds  iu  the  abdomen  it 
occasionally  hap})ens  that  the  bullet  is  arrested  in  the  lumen  of  the 
intestine   and   carried  along  by  the  fecal  current. 

The  Cranial  Cavity. — The  body  now  lies  upon  the  back,  with  the 
head  at  the  end  of  the  table,  the  neck  and  occiput  resting  uj)()n  a 
wooden  block  which  brings  the  head  well  forward.  The  hair,  espe- 
cially when  long,  must  be  parted  along  the  intended  line  of  incision, 
which  runs  from  the  apex  of  the  mastoid  process  behind  one  ear  over 
the  vertex,  to  a  corresponding  })oint  on  the  opposite  side.  In  I)al(l 
persons  the  incision  may  be  carried  across  the  vertex  further  poste- 
riorly, in  order  better  to  hide  the  resulting  mutilation.  This  incision  is 
made  by  means  of  one  stroke  of  the  knife,  dividing  all  the  soft  layers 
down  to  the  periosteum.  The  scalp,  by  means  of  dissection  and  by 
traction  with  the  fingers,  is  then  reflected  on  each  side  of  the  incision, 
anteriorly  as  far  as  the  supra-orbital  ridges,  the  flap  being  folded  over 
the  face;  and  posteriorly  down  a  little  below  the  external  occipital  pro- 
tuberance, the  flap  l)eing  then  placed  under  the  occiput.  Laterally,  the 
scalp  should  be  loosened  down  to  the  external  auditory  canals.  The 
exposed  skull-cap  is  now  removed  by  means  of  the  saw.  The  incision 
should  follow  the  greatest  circumference  of  the  skull,  passing  anteriorly 
through  the  glabella  and  posteriorly  through  the  occipital  protuberance, 
and  along  corresponding  points  to  the  right  and  left.  This  line  may  be 
mapped  out  beforehand  by  means  of  the  knife,  and  it  is  always  well  to 
mcise  the  temporal  fascia  and  muscles  down  to  the  bone  along  the  pro- 
posed saw-cut.  Many  prefer  to  remove  the  skull-cap  by  an  incision 
which  runs  on  each  side  of  the  center  of  the  forehead  to  the  base  of 
the  mastoid  process,  and  from  these  points  Ixickward  and  upward  to  a 
point  a  little  above  the  external  occipital  protuberance,  thus  removing 
a  wedge-shaped  section  of  the  calvaria.  The  circular  incision  is  to 
be  preferred  because  it  facilitates  certain  important  cranial  measure- 
ments. 

When  beginning  to  saw,  the  examiner  should  stand  to  the  left  of  the 
body ;  the  incision  should  be  started  in  the  region  of  the  glabella,  and, 
while  sawing  with  the  right  hand,  the  left  is  ajiplied  on  the  anterior 
part  of  the  scalp,  covering  the  face  and  steadying  the  head,  which  is 
gradually  turned  to  the  left  as  the  sawing  proceeds  along  the  right  side 
as  far  as  possible.  When  the  incision  cannot  be  carried  any  furtlier 
posteriorly,  the  saw  is  lifted  out  and  the  head  twisted  as  far  to  the  right 
as  possible,  and  in  this  position  the  sawing  is  then  completed. 

The  saw  furrow  should  be  continuous  and  even,  and  great  care 
should  be  exercised  not  to  injure  the  pachymeninx  or  the  brain.  In 
medicolegal  cases  the  skull  should  be  sawed  completely  through  all 
around,  so  as  to  avoid  entirely  the  use  of  the  mallet  and  chisel,  which 
might  produce,  or  be  alleged  to  produce,  misleading  fractures.  The 
calvaria  are  loosened  by,  inserting  a  chisel  or  cross-bar  into  the  saw-cut 
and  turning  the  instrument  on  its  long  axis.  After  this  the  skull-cap 
may  be  jerked  away  from  the  dura  by  means  of  the  fingers  or  a  blunt 

Vol.  I.— 3 


O-i      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMIXATIOX. 

hook  inserted  underneath  its  margins  anteriorly.  If  the  fingers  are 
used,  great  care  must  be  taken  lest  the  skin  be  scratched. 

If  the  dura  be  so  unusually  adherent  to  the  skull  that  traction  seems 
liable  to  cause  injury  to  the  brain,  then  the  membrane  must  be  divided 
along  the  saw-cut  with  a  probe-pointed  scissors ;  and  after  cutting  the 
falx  cerebri  across  at  its  anterior  attachment,  the  calvaria  and  dura  are 
removed  together,  the  falx  being  also  severed  at  its  posterior  end.  The 
same  procedure  may  be  used  in  the  case  of  quite  young  children,  in 
whom  the  dura  and  skull  are  still  intimately  adherent. 

The  greatest  circumference  of  the  skull-cap  can  now  be  measured  by 
placing  a  tape-line  along  the  sawed  margin,  and  the  length  determined 
as  well  as  the  width,  the  latter  measurement  running  at  right  angles 
across  the  center  of  the  long  diameter.  Other  diameters  and  measure- 
ments can  also  be  taken.  The  form  of  the  skull-cap,  the  thickness  of 
the  bone,  the  quantity  of  diploe,  the  sutures,  etc.,  are  now  examined. 

The  exposed  surface  of  the  dura  is  then  inspected.  The  degree  of 
tension  should  be  tested  by  pinching  up  a  fold  near  the  apex  of  the 
frontal  lobes ;  the  longitudinal  sinus  is  incised,  and  its  contents  exam- 
ined. The  next  step  consists  in  dividing  the  dura  on  each  side 
along  the  sawed  edge  of  the  skull,  from  the  anterior  to  the  posterior 
extremity  of  the  falx  cerebri,  with  the  point  of  a  scalpel  or  small 
scissors,  using  great  care  not  to  puncture  the  pia.  The  dura  over  each 
half  of  the  convexity  is  then  folded  in  turn  over  upon  the  opposite 
half,  so  as  to  expose  the  under  surface  to  full  view  ;  abnormal  contents 
of  the  subdural  s])ace  are  now  readily  seen.  If  adhesions  are  found 
between  the  pia  and  the  dura,  then  the  corresponding  dural  area  should 
be  cut  away  and  allowed  to  remain  adherent,  because  forcilile  detach- 
ment might  injure  the  subjacent  cortex.  The  fldx  cerebri  is  severed 
near  its  attachment  to  the  crista  galli,  and  the  dura  turned  backward  at 
the  same  time  that  the  pial  (superior  cerebral)  veins  emptying  into  the 
longitudinal  sinus  are  either  torn  or,  preferably,  cut  across ;  the  dura  is 
left  hanging  at  the  occiput.  The  color,  vascularity,  etc.,  of  the  pia  are 
now  readilv  made  out,  and  the  brain  is  removed  from  its  cavitv  in  the 
following  manner  : 

Place  the  block  under  the  neck,  so  that  the  head  hangs  backward  a 
little ;  pass  the  fingers  of  the  left  hand  between  the  skull  and  the 
frontal  lobes,  and  srentlv  draw  these  backward.  As  the  brain  mass 
sloAvly  leaves  the  cavity  by  its  own  weight,  supported  all  the  time  by 
the  left  hand,  everything  that  connects  the  brain  with  the  base  of  the 
skull  is  divided — to  wit :  the  olfactory  nerves,  the  optic  nerves,  the 
carotid  vessels,  the  peduncle  of  the  hypophysis,  and  the  third,  fourth, 
and  sixth  nerves.  When  the  tentorium  cerebelli  is  reached,  it  is  cut  with 
the  point  of  the  knife  along  its  attachment  to  the  superior  margin  of 
the  petrous  portion  of  the  temporal  bone,  great  caution  being  used  not 
to  damage  the  cerebellum.  Then  the  fifth,  seventh,  eighth,  ninth, 
tenth,  eleventh,  and  twelfth  nerves,  as  well  as  the  vertebral  arteries, 
are  cut.  The  onlv  remaining^  connection  of  the  brain  is  that  with  the 
spinal  cord,  from  which  it  should  be  divided  as  nearly  at  right  angles 


EXAMINATION    OF    THE    BODY.  35 

as  possible  by  means  of  the  sharp  mvehjtome.  When  an  ordinary 
scalpel  is  used,  the  handle  should  be  elevated  as  much  as  possible,  and 
the  division  made  with  one  precise  stroke  of  the  knife.  This  division 
should  always  be  made  as  far  below  the  medulla  as  practicable.  While 
the  left  hand  suppnrts  the  brain  as  before,  the  fingers  of  the  right  hand 
are  placed  upon  the  ventral  surface  of  the  cerebellum,  and  the  whole 
mass  is  allowed  to  fall,  or  is  raised,  out  of  the  cranial  cavity,  weighed, 
and  placed  with  the  convexity  downward  upon  a  suitable  plate. 

The  base  of  the  skull  is  now  examined,  the  dural  sinuses  are  incLsed 
and  inspected,  and  the  pachymeninx  is  loosened  and  removed  so  that 
the  inner  surface  of  the  bones  may  be  inspected  for  fractures  and  other 
lesions.  The  hypophysis  may  be  removed  from  the  sella  turcica  by 
carefully  cutting  away  the  dural  diaphragm,  which  covers  this  cavity. 

The  Brain. — The  basal  leptomeninx,  the  cerebral  nerves,  and  the 
basal  vessels  are  examined  while  the  brain  lies  upon  its  convex  surface. 
The  basal  arteries  require  careful  examination  because  of  the  frequent 
occurrence  of  arteriosclerosis,  embolism,  thrombosis,  etc.;  they  should 
be  dissected  free  from  the  leptomeninx,  the  layer  of  the  arachnoid 
which  bridges  the  Sylvian  fissure  incised,  and  the  temporosphenoid 
separated  with  the  fingers  from  the  parietal  lobes,  so  as  to  expose  the 
middle  cerebral  arteries  throughout  their  whole  course.  The  frontal 
lobes  should  be  separated  so  as  to  bring  into  view  the  anterior  cerebral 
vessels  as  they  curve  over  the  corpus  callosum,  and  the  posterior  cere- 
bral vessels  traced  backward  between  the  cerebellum  and  the  occipital 
lobes.  The  arteries  may  be  cut  across  or  opened  longitudinally  here 
and  there,  in  order  to  determine  their  contents  and  the  condition  of 
their  walls. 

The  brain  is  then  turned  over,  and  a  systematic  study  is  made  of 
its  general  contour,  fissure  formation,  and  peculiarities  of  the  cerebral 
surface.  All  pathologic  areas  in  the  leptomeninx,  as  well  as  in  the 
brain  itself,  are  carefully  examined  and  exactly  localized.  The  local- 
ization of  surfliee  lesions  is  made  easier  by  the  use  of  outlines  of  the 
In-ain  upon  which  the  topography  of  areas  of  disease  may  be  indicated. 
Whenever  necessary,  the  pia  may  be  detached,  but  it  should  not  be 
stripjied  off  from  areas  of  the  cortex  that  are  to  be  examined  micro- 
scopically because  of  the  tearing-out  of  vessels  entering  and  leaving 
the  brain,  necessarily  disturl^ing  the  cortical  structure.  To  remove  the 
pia  completely,  which  may  be  advisable  in  order  better  to  study  the 
exact  size  and  form  of  the  convolutions,  the  artery  of  the  corjius 
callosum  is  cut  across  in  front  and  at  the  posterior  border ;  the  inter- 
mediate part  is  grasped  with  forceps,  and  the  membrane  detached  little 
by  little.  When  sufficient  has  been  loosened  to  permit  it,  the  free  part 
may  be  grasped  with  one  hand,  which  continues  the  stripping,  wlrile 
the  other  pushes  the  brain  away  from  the  pia.  Should  the  membrane 
tear,  it  should  be  picked  up  again  with  forceps  at  the  bottom  of  a 
sulcus  in  which  run  the  large  and  strong  vessels. 

The  methods  of  sectioning  the  brain  are  numerous,  and  it  is  not 
possible  to  recommend  any  one  method  as  the  most  suitable  under  all 


36      THE    TECHNIC    OF    MEDICOLEGAL,    POSTMOETEM    EXAMLNATION. 

circumstances.  In  medicolegal  cases  in  Avhich  it  is  necessary  to  deter- 
mine at  once  the  presence  or  absence  within  the  brain  of  actual  or  con- 
tributing causes  of  death  the  more  mutilating  methods,  by  which  the 
brain  is  cut  into  very  small  pieces,  may  be  used.  When  it  is  not 
necessary  to  subdivide  the  brain  minutely,  or  Mhen  it  is  to  be  fixed  and 
hardened  and  subsequently  exammed  microscopically,  then  the  division 
into  transverse  sections  is  a  very  satisfactory  way  of  examining  this 
oro-an,  either  in  the  fresh  state  or  after  it  has  been  hardened  in  Miiller's 
fluid  or  solutions  of  formaldehyd.^  The  following  method  will  answer 
in  almost  all  cases  : 

The  brain  is  first  divided  into  three  parts,  one  including  the  pons, 
medulla,  and  cerebellum  and  the  remaining  two  of  the  cerebral  hemi- 


FiG.  2.— Board  fitted  with  parallel  grooves,  1  cm.  apart,  for  the  purpose  of  dividing  the  brain  into 
transverse  sections  as  recommended  by  Henschen. 

spheres.  This  division  is  accomplished  by  dividing  the  cerebral 
peduncles  transversely  anteriorly  to  the  corpora  quadrigemina,  and  then 
removing  the  pons,  etc.,  and  by  separating  the  two  hemispheres  from 
each  other  by  a  median  sagittal  section  through  the  optic  chiasm,  the 
infundibulum,  the  tuber  cinereum,  the  posterior  perforated  space,  the 
septum  pellucidum,  and  the  commissures  of  the  third  ventricle  and  the 
corpus  callosum.  The  hemispheres  can  now  be  divided  into  transverse 
sections  according  to  different  plans.  A  board  about  35  or  40  cm.  (13 
to  16  in.)  square,  with  the  surface  divided  into  a  number — at  least  25 — 

^  A  brain  kept  but  a  few  days  in  5  or  10  per  cent,  solutions  of  formalin  (40 
per  cent,  solution  of  fornialdehyd)  has  acquired  a  most  desirable  consistence  for 
handlins;. 


EXAMINATION    OF    THE    BODY.  37 

of  })arallel  furrows  exactly  1  cm.  (0.89  in.)  apart  (Fig.  2)  may  be  used 
(Henscheu).  Placing  the  hemisphere  with  the  median  surface  down  and 
at  right  angles  to  the  furrows,  it  can  be  nicely  separated  into  transverse 
sections  exactly  1  cm.  (0..'>Ji  in.)  or  more  thick,  as  the  case  may  be,  the 
knife  being  guided  by  the  furrows  in  which  the  point  is  to  be  held. 

By  this  plan  is  secured  a  sufficiently  minute  subdivision  for  gross 
l)urposes,  as  the  size  of  the  ventricles,  their  lining  and  contents,  as  w^ell 
as  foci  and  tracts  of  disease,  are  well  displayed,  at  the  same  time  pre- 
serving the  topographic  relations  ;  and  the  sections,  when  hardened, 
remain  serviceable  for  microscopic  pur})0scs. 

The  above  method  is  recommendablc  for  formalin  brains ;  in  the 
case  of  fresh  brains  the  sections  had  better  be  made  2  cm.  (0.79  in.) 
thick.  In  hardening  a  brain  which  has  been  divided  when  fresh  in  this 
manner,  care  must  be  taken  to  protect  the  sections  by  means  of  absorb- 
ent cotton  against  bending  or  distortion  from  mutual  pressure. 

According  to  the  method  of  Pietres,  the  transverse  sections  ran 
parallel  to  the  central  fissure,  and  are  consequently  not  exactly  trans- 
verse to  the  long  brain  axis.  The  hemisphere  is  placed  upon  its 
median  surface  and  fixed  with  the  left  hand,  while  the  following 
sections  are  made  parallel  to  the  central  fissure : 

1.  The  prefrontal  section  through  the  anterior  half  of  the  third 
frontiil  convolution. 

2.  The  pediculofrontal  section,  about  2  cm.  (0.79  in.)  in  front  of 
the  central  fissure. 

3.  The  frontal  section  through  the  anterior  central  convolution. 

4.  The  parietal  section  through  the  posterior  central  convolution. 

5.  The  pediculoparietal  section,  about  3  cm.  (1.18  in.)  behind  the 
central  fissure. 

6.  The  occipital  section  across  the  occipital  lobe. 

When  the  hemispheres  are  divided  from  before  backward,  according 
to  either  of  these  plans,  the  sections  of  each  hemisphere  may  be  placed 
in  parallel  rows  upon  a  plate  or  tray  with  the  posterior  surfaces 
upward,  thus  presenting  a  good  opportunity  to  compare  corresponding 
points  in  the  two  halves  of  the  brain. 

The  cerebellum  is  examined  in  this  manner  :  A  sagittal  section  is 
made  through  the  center  of  the  vermis  by  means  of  which  the  fourth ' 
ventricle  is  also  opened,  then  the  restiform  bodies  and  the  processus 
cerebelli  ad  corpora  quadrigemina  et  ad  poutem  are  divided  on  each  side 
vertically  to  their  long  axes,  whereby  the  cerebellar  hemispheres  are 
loosened  completely.  Each  hemisphere  is  then  divided  by  a  horizontal 
section,  starting  from  the  cut  surface  of  the  vermis,  into  an  upper  and 
a  loAver  half,  thus  exposing  the  nucleus  dentatus. 

The  pons  and  medulla  are  divided  into  three  or  four  segments  by 
complete  and  exactly  transverse  incisions  which  expose  their  interior 
sufficiently,  at  the  same  time  leaving  the  structures  in  proper  condition 
for  hardening  and  microscopic  examination. 

The  cerebnd  hemispheres  can  also  be  examined  by  means  of  a  series 
of   horizontal   incisions,   according   to   the    old  method   introduced   by 


38      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

Virchow.  A  brain  incised  in  this  manner  is  less  favorable  for  subse- 
quent microscopic  examination  with  a  view  to  studying  and  tracing  the 
lesions  topographically. 

The  whole  brain  lies  base  downward,  and  the  two  hemispheres  are 
separated  until  the  corpus  callosura  is  exposed ;  placing  the  left  hand 
on  the  left  hemisphere,  the  thumb  on  the  median  aspect,  and  lifting  the 
hemisphere  up,  a  vertical  incision  is  made  into  the  roof  of  the  ventricle 
in  the  angle  formed  by  the  junction  of  the  corpus  callosum  with  the 
median  surface  of  the  hemisphere,  thus  opening  the  ventricle  fully. 
The  posterior  horn  is  opened  by  cutting  backward  and  outward  into  the 
occipital  lobe ;  and  the  anterior  by  dividing  the  frontal  lobe  in  a  direc- 
tion a  little  outward  and  forward,  and  then  connecting  the  extremities 
of  these  incisions  by  a  nearly  vertical  cut  outside  of  the  basal  ganglia, 
throngh  the  floor  of  the  ventricle,  and  dov/n  to,  but  not  quite  through, 
the  cortex  of  the  inferior  surface.  The  same  incisions  are  made  on  the 
right  side,  and  both  lateral  ventricles  are  now  fully  exposed.  The 
corpus  callosum,  which  has  been  kept  in  the  median  line  during  these 
manipulations,  is  now  raised  up  with  the  left  hand  and  a  knife-point 
entered  through  the  foramen  of  Monro,  which  divides  the  corpus 
callosum  in  a  direction  forward  and  upward ;  the  parts  behind  this 
division  are  raised  up  and  turned  back,  uncovering  the  velum  inter- 
positum  and  its  plexus,  which  are  also  carefully  lifted  up,  exposing  the 
third  ventricle.  A  vertical  incision  is  next  made  into  the  center  of  the 
vermes,  opening  the  fourth  ventricle,  so  that  now  the  entire  series  of 
encephalic  cavities  are  open  to  inspection. 

The  cerebrum  is  further  examined  by  dividing  the  left  hemisphere, 
supported  by  the  left  hand,  into  t^^o  equal  halves  from  before  back- 
ward by  means  of  a  long  incision  that  extends  down  to,  but  not 
through,  the  cortex ;  and  each  resulting  Avedge-shaped  half  is  again 
bisected  in  the  same  manner  until  the  subdivision  is  regarded  as  suf- 
ficiently minute.  The  same  incisions  are  made  into  the  right  hemi- 
sphere. The  basal  ganglia  are  laid  open  by  a  series  of  radiating 
incisions,  the  common  point  of  origin  of  which  is  the  cerebral  peduncle 
on  each,  whence  the  cuts  radiate  like  the  ribs  of  a  fan. 

The  c6rebellmii,  pons,  and  medulla  are  best  examined  as  before 
described. 

The  Spinal  Column  and  Cord. — The  body  lies  prone,  the  neck  and 
upper  part  of  the  chest  resting  upon  a  wooden  block.  A  continuous 
incision  is  made  from  the  occipital  protuberance  along  the  spines  of  the 
vertebrae  down  to  the  center  of  the  sacrum,  and  the  skin  and  subcuta- 
neous tissue  are  dissected  loose  for  a  short  distance  on  each  side  of  the 
median  line.  Deep  incisions  are  now  made  into  the  muscle,  and  all 
soft  parts  are  dissected  away  from  the  laminae,  so  that  the  vertebral 
arches  are  fully  exposed.  Then  the  laminae  are  sawed  through  near 
the  articular  processes,  so  as  to  open  the  spinal  canal.  This  is  readily 
accomplishcnl  with  the  adjustable,  double-bladed  vertebral  saw,  the 
handle  being  held  in  the  right  hand,  the  left  hand  pressing  the  saw 
against  the  bones.     A  single-bladed  saw,  curved  and  rounded  at  the 


EXAMINATION    OF    THE    BODY.  39 

])()int,  also  answers  very  avoII,  and  is  perhaps  a  little  safer,  as  it  is  not 
so  liable  to  impaction  (Fiti'.  1). 

The  entire  posterior  areh\vay  slioiild  be  sawed  through,  so  that  every 
spinous  process  is  readily  movable.  On  account  of  tlu;  greater  curva- 
ture of  the  cervical  vertebra),  this  part  usually  requires  special  atten- 
tion before  the  arches  are  severed  comjiletely.  Then  the  ligaments 
between  the  last  lumbar  vertebra  and  the  sacrum  are  cut  across,  and 
all  the  arches,  lield  together  by  the  liganienta  subtlava,  may  be  remove-d 
in  one  continuous  chain  by  means  of  a  strong  forceps.  The  sjiinal 
canal  should  be  opened  in  this  manner  only,  and  without  the  use  of  the 
mallet  and  chisel.  Van  Gieson  showed  that  there  is  great  danger  of 
indirect  mechanical  disturbance  of  the  substance  of  the  cord  wlien  the 
usual  violent  procedures  are  resorted  to,  to  say  nothing  about  the 
liability  of  directly  crushing  the  cord.  In  young  children  the  arches 
may  be  cut  through  by  means  of  a  bone  scissors. 

In  some  pathologic  institutes  the  cord  is  taken  out  from  the  front 
after  removal  of  the  vertebral  bodies  l)y  means  of  Brunetti's  chisel,  the 
pointed  guard  of  which  is  inserted  into  the  vertebral  canal  bet^veen 
two  pedicles,  the  cutting-edge  resting  against  the  upper  pedicle,  and  the 
long  axis  being  parallel  to  the  vertebral  colunm  ;  the  pedicles  are  then 
cut  off  on  both  sides  by  means  of  blows  from  the  mallet.  In  this 
manner  the  cord  is  expeditiously  removed  through  the  long  anterior 
incision  after  the  organs  have  been  taken  out,  and  the  method,  therefore, 
may  be  of  advantage  in  limited  or  private  autopsies,  but  there  remams 
some  risk  of  mechanically  injuring  the  cord. 

After  the  removal  of  the  arches  the  posterior  surface  of  the  dura  is 
incised  in  the  median  line.  The  spinal  nerves  are  then  cut  across  with 
a  small  scalj)el  as  far  out  into  the  intervertebral  foramina  and  away 
from  the  dura  as  possible,  while  the  cord  is  lield  out  of  the  way  ])y 
means  of  forceps  grasping  the  dura.  Moderate  traction  upon  the  dura 
will  usually  lift  the  intervertebral  ganglia  out  so  that  the  nerves  can  be 
severed  peripherally  to  the  ganglia.  Then  the  branches  of  the  cauda 
equina  are  cut  across,  and,  while  lifting  the  cord  with  forceps  holding 
the  dura,  the  attachments  between  the  dura  and  the  canal  are  rapidly 
severed.  Lastly,  the  entire  circumference  of  the  dura  is  cut  away  from 
the  margin  of  the  foramen  magnum  and  the  cord  lifted  out  upon  a  suit- 
able board  or  tray.  During  these  manipulations  great  care  must  be 
taken  not  to  bend,  twist,  or  compress  the  cord,  which  should  not  be 
grasped  directly,  but  held  l:)y  forceps  pinching  the  dura. 

The  cord  is  now  examined  more  thoroughly,  and,  by  means  of  a 
sharp,  thin,  clean  knife,  cut  into  transverse  sections  about  2  cm.  (0.79 
in.)  or  so  in  length ;  the  division  between  each  segment  should  be  com- 
plete, otherwise  there  will  be  traction  upon  the  uncut  nerve-fibers,  and 
the  division  should  always  pass  between  two  ])airs  of  nerve-roots. 
There  is  no  danger  of  the  segments  fallmg  apart,  because  they  are  lu-ld 
together  by  the  dura.  As  the  sections  are  made,  care  should  be  taken 
that  the  cord  is  not  compressed. 

Subsequently,  or  before  incised,  the  cord  may  be  hardened  in  4  per 


40      THE    TECHXIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

cent,  formaldehyd  solution  (10  per  cent,  of  the  commercial  article)  by- 
suspending  it  by  one  end  from  a  cork  floating  on  the  liquid  in  a  high 
bottle,  some  kind  of  a  weight  being  attached  to  the  lower  extremity. 

After  the  removal  of  the  cord  the  structures  composing  the  canal 
are  examined  for  fractures,  dislocations,  etc. 

The  Orbits. — On  account  of  its  thinness,  the  roof  of  the  orbital 
cavities  is  easily  chiseled  away,  and  the  contents  of  the  cavities  can  be 
thoroughly  examined  without  any  deformity  being  visible  anteriorly. 
Even  the  posterior  half  of  the  eyeball  may  be  cut  away,  and  the 
remaining  ])art  of  the  eye  kept  in  place  by  plugging  the  orbit  with 
cotton.  When  demanded,  or  when  there  is  no  objection  on  account  of 
cosmetic  reasons,  the  eyeball  may  be  removed  in  toto,  either  from  above 
or  through  the  palpebral  fissure. 

The  Ears. — Tiie  ear  may  be  opened  in  loco  by  chiseling  away  the 
roof  of  the  tympanum,  going  backward  so  far  as  to  open  also  the 
mastoid  cells.  When  it  is  necessary  to  remove  the  ear  completely,  the 
incision  for  removing  the  scalp  is  prolonged  down  upon  the  neck,  the 
skin  and  subcutaneous  tissue  are  dissected  loose,  and  the  external 
auditory  canal  is  cut  across.  The  dissection  is  continued  anteriorly  as 
far  as  the  middle  of  the  zygoma  and  the  angle  of  the  jaw,  and  poste- 
riorly toward  the  middle  of  the  occiput ;  the  petrous  portion  of  the 
temporal  bone  is  now  loosened  by  two  saw-cuts  that  meet  at  its  apex 
and  diverge  externally,  so  as  to  include  the  mastoid  process.  The  bone 
is  now  turned  forcibly  outward,  the  temporomaxillary  joint  usually 
being  opened,  and  the  remaining  soft  tissues  cut  across. 

The  ear  may  be  further  examined  at  leisure  according  to  methods 
described  in  special  works. 

The  Nasal  and  Accessory  Cavities. — The  best  method  for  examin- 
ing the  nose  and  its  accessory  cavities  is  that  described  by  Harke. 
After  removing  the  brain  in  the  ordinary  manner,  the  soft  parts  are 
reflected  anteriorly  down  to  the  supra-orbital  margins  and  the  root  of 
the  nose,  and  posteriorly  down  below  the  foramen  magnum.  This  re- 
quires that  the  incisions  for  removing  the  scalp  be  prolonged  on  each 
side  along  the  sternomastoid  muscle  to  about  the  middle  of  the  neck ; 
then  the  skull  is  divided  with  the  saw  into  two  equal  parts  in  the  median 
line,  sawing  from  behind  forward,  through  the  occipital  bone,  the  sella 
turcica,  the  body  of  the  sphenoid  bone,  and  the  ethmoid  and  frontal 
bones.  The  halves  are  pressed  apart  by  means  of  a  strong  effort,  aided 
by  the  hammer  and  chisel  when  necessary  on  account  of  resistance  in 
the  region  of  the  foramen  magnum. 

As  the  skull  is  forced  apart  the  nasal  bones,  the  hard  palate,  and 
the  alveolar  process  of  the  superior  maxillary  bone  are  fractured,  but 
without  injury  to  the  soft  parts.  The  frontal  and  sphenoid  sinuses,  the 
nasal  passages,  and  the  septum  are  now  readily  inspected ;  bacteriologic 
inoculations  may  be  made  and  pieces  removed.  Usually  the  median 
incision  passes  a  little  to  one  side,  so  that  the  partitions  between  the 
cavities  have  to  be  removed  Avith  forceps  and  strong  scissors,  and  in  this 
manner  the  maxillary  sinuses  are  also  opened  sufficiently. 


EXAMIXATION    OF    THE    BODY.  41 

When  the  two  halves  of  the  skull  are  fokled  together  again,  the  face 
assumes  its  usual  appearance,  and  the  incisions  upon  the  neck  are 
situated  so  far  posteriorly  that  when  sutured  they  are  not  easily  visible 
as  the  body  lies  in  the  coffin. 

Opening  the  Cavities  of  the  Trunk. — The  body  lies  on  the  back, 
and  the  head  should  hang  over  the  end  of  the  table  so  as  to  bring  the 
neck  well  forward.  The  examiner  stands  to  the  right  of  the  bodv,  and 
makes  an  incision  from  the  hyoid  bone  to  the  pubcs,  j)assing  to  the  left 
of  the  navel.  This  incision  is  made  with  the  ^hole  vdc^e  of  the  section 
knife,  which  is  held  nearly  horizontally.  In  many  cases  it  may  appear 
advisable  to  begin  the  incision  a  little  lower  in  the  neck,  in  order  to 
avoid  any  visible  disfigurement.  The  soft  covering  of  the  thorax  is  at 
once  cut  through  to  the  bone,  while  over  the  abdomen  the  primary  incision 
extends  only  into  the  subcutaneous  tissue  or  muscles.  An  o})ening  is 
then  made  into  the  abdominal  cavity,  just  below  the  eusiform  cartilage, 
and  two  fingers  are  passed  in  ;  with  these  the  wall  is  lifted  up,  and,  as 
the  fingers  are  spread  apart,  the  volar  surfaces  being  directed  toward 
the  pelvis,  the  tissues  are  divided  between  them  down  to  the  symphvsis 
pubis.  In  order  to  turn  the  abdominal  walls  more  easily  to  the  side, 
the  recti  muscles  are  severed  subcutaneously  near  their  pubic  attach- 
ments (Fig.  3).  In  the  case  of  laparotomy  having  been  done,  the 
incision  into  the  abdominal  wall  should  pass  to  one  side  of  the  laparot- 
omy wound,  in  order  better  to  observe  the  relations  between  the  intes- 
tines and  the  sutures. 

On  opening  the  abdomen  the  escape  of  gas  or  fluid  must  be  noted ; 
the  latter  may  be  collected  and  measured,  in  order  to  prevent  its  con- 
tinuous escape,  if  present  in  large  quantities. 

The  abdominal  wall  is  now  pulled  outward  over  the  costal  arch  with 
the  left  hand,  and  the  soft  parts  are  rapidly  cut  across  from  the  xiphoid 
appendix  outward  to  the  last  rib  on  each  side.  This  is  followed  by  the 
loosening  of  the  soft  tissues  over  the  sternum  and  the  costal  cartilages ; 
the  left  hand  pulls  the  covering  firmly  away  from  the  chest-wall,  A\hile 
the  deep  attachments  are  divided  l)y  long  sweeping  incisions  that  ])ass 
from  below  upward  and  outward.  The  soft  parts  are  dissected  in  this 
manner  on  both  sides  beyond  the  costochondral  junctions  and  up  to  the 
superior  thoracic  aperture.  During  this  process  the  mammary  glands 
may  be  incised  and  examined  from  behind.  In  the  neck  the  lower 
ends  of  the  sternocleidomastoid  muscles  are  cut  across  and  the  cellular 
tissue  under  these  muscles  divided  on  each  side,  if  possible,  as  high  up 
as  the  hyoid  bone. 

A  general  inspection  of  the  abdominal  cavity  should  be  made  at 
this  time,  in  order  to  avoid  any  possible  change  in  the  position  of  the 
organs,  or  mixture  of  fluids  that  might  ensue  after  o})ening  the  thorax. 
In  some  cases — as,  for  instance,  poisoning  or  gunshot  wounds  of  the 
intestines  or  perforation  peritonitis — it  is  well  to  finish  the  examination 
of  the  abdominal  organs  first,  in  order  to  clear  up  all  the  problems 
under  the  most  simple  and  favorable  conditions.     In  such  cases  the 


42       THE    TECHNIC    OF    MEDICOLEGAL    POSTMOETEM    EXAMINATION. 


general  order  of  procedure   is   modified  as  found  necessary  in   conse- 
quence of  the  special  conditions  of  the  single  case. 

Inspection  of  the  abdominal  cavity  includes  a  thorough  investiga- 
tion in  regard  to  the  contents  of  the  cavity,  the  color  and  condition  of 
the  peritoneal  surfaces,  the  position  of  the  organs,  abnormal  adhesions, 
hernias,  intestinal  malposition  and  obstructions,  etc.  When  intestinal 
perforation  is  suspected,  the  whole  gastro-intestinal  tract  should  be 
examined  minutely  until  it  is  settled  as  to  the  presence  or  absence  of 
perforation.  Finally  the  position  of  the  dia])hragm  is  determined  by 
inserting. the  hand  under  the  costal  arches  up  to  the  highest  point,  and 
then  pressing  the  fingers  against  the  chest-wall,  when  the  height  is  read 
off  with  reference  to  a  rib  or  interspace ;  the  same  point  should  be 


Fig.  3.— The  body  cavities  opened  and  the  sternum  removed. 

selected  on  both  sides.     In  tliis  way  information  is  obtained  in  regard 
to  the  degree  of  distention  of  the  pleural  cavities. 

The  chest  is  next  opened  by  dividing  the  cartilages  from  the  second 
to  the  tenth  rib,  at  a  point  about  0.5  or  1  cm.  (0.195  or  0.39  in.)  inside 
of  the  costochondral  junction.  The  knife  is  held  horizontally,  so  tliat 
as  one  cartilage  is  cut  the  edge  rests  immediately  on  the  next ;  in  this 
way  the  cartilages  are  cut  rapidly  without  removing  the  knife  from  the 
chest-wall  and  without  any  danger  of  injury  to  the  organs  of  the 
thorax.  When  the  cartilages  are  calcified,  they  are  divided  with  an 
ordinary  saw.  In  cases  of  suspected  pneumothorax  a  small  pocket 
should  first  be  made  in  the  soft  parts  over  an  intercostal  space,  and 
this  filled  with  water.  On  puncturing  the  pleura  the  gas  will  bubble 
through  the  Avater ;  or  a  hollow  needle  may  be  plunged  through  the 


EXA.Ml.NAIlUN    OF    TllK    15UDV.  43 

wall  and  the  point  held  under  water.  The  sternum  is  now  lifted  u[) 
with  the  left  hand,  tiie  insertion  of  the  dia[)hraii::ni  divided  elose  to  the 
bone,  and  the  eellular  tissue  of  the  anterior  niediastiiuuii  ra])idly  eut 
through  up  to  the  lower  margin  of  the  eartilages  of  the  tirst  ribs. 
These  are  divided  with  a  pointed  knife  from  below,  and  a  little  farther 
away  from  the  sternum  than  where  the  second  cartilages  were  severed, 
great  care  being  taken  not  to  incise  the  subjacent  large  veins.  The 
sternum  can  now  be  raised  toward  the  neck,  and  the  capsules  of  the 
sternoclavicular  articulations  incised  from  below,  first  on  one  side  and 
then  on  the  other,  after  which  the  remaining  structures  and  ligaments 
are  cut  easily  and  the  manubrium  completely  liberated.  If  to(j  nuich 
force  is  used  in  lifting  up  the  sternum,  fracture  of  the  manubrium  may 
result  near  or  at  the  junction  with  the  middle  piece.  By  grasping  the 
clavicle  and  moving  it,  the  exact  location  of  the  sternoclavicular  joint 
is  easily  determined  (Fig.  3). 

The  .Organs  of  the  Neck. — In  medicolegal  cases  a  painstaking 
examination  of  the  structures  of  the  neck  is  necessary,  especially  when 
death  is  thought  to  have  resulted  from  drowning  or  strangulation,  or 
when  suspicious  external  marks  are  observed. 

First,  the  thyroid  gland  should  be  loosened  from  the  surrounding 
muscles,  its  size  and  form  determined,  and  its  interior  exposed  by  con- 
verging incisions  through  each  lobe,  from  above  downward.  Then  the 
large  vessels  and  nerves,  as  well  as  the  lymphatic  glands  and  eventually 
the  thoracic  duct,  are  isolated.  Simultaneously  the  deep  muscles  and 
other  structures  may  be  investigated  for  bruises  and  extravasations.  In 
case  of  hanging,  or  strangulation  by  other  means,  ecchymoses  are 
occasionally  found  in  the  intima  of  the  carotid  arteries  and  jugular 
veins.  After  completing  this  dissection,  the  trachea  and  larynx  may 
be  opened  in  the  median  line  from  below  upward  by  means  of  the  point 
of  the  scalpel.  If  the  cartilages  are  calcified,  the  bone  scissors  are 
used,  which  are  also  necessary  to  divide  the  hyoid  bone.  The  contents 
of  the  trachea  and  larynx  are  open  to  inspecticin  before  being  disturbed 
during  the  removal  of  the  organs ;  the  finger  may  be  inserted  carefully 
in  order  to  detect  possible  foreign  bodies  in  the  entrance  to  the  larynx 
or  in  the  pharynx. 

Tlie  tongue  and  the  pharjiix  are  removed  by  passing  a  scalpel  into 
the  mouth  from  below  at  the  right  or  the  left  angle  of  the  jaw,  along 
the  inner  surface  of  the  bone,  and  then  cutting  round  to  the  oj^posite 
angle  in  close  ap]iosition  to  the  bone.  The  tongue  is  then  brought  out 
below  the  mandible,  and  pulled  downward*  with  the  left  hand,  the 
attachment  of  the  soft  to  the  hard  palate  divided,  the  cuts  going  above 
the  tonsils,  and  the  posterior  pharyngeal  ^\'all  incised  transversely 
against  the  spinal  column.  Downward  traction  on  the  tongue  enal)les 
one  readily  to  separate  the  retropharyngeal  connective  tissue,  and  the 
connections  between  the  esophagus  and  the  spine  yield  very  readily,  so 
that  the  organs  of  the  neck  are  now  freed  down  to  the  superior  opening 
of  the  thorax. 

The  enterotome  is  now  inserted  into  the  previous  incision  into  the 


44       THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMLSTATION. 

trachea  and  larynx,  and  the  epiglottis  [note  the  form  of  the  epiglottis 
before  dividing]  and  the  tongue  divided  in  two  along  the  median  line. 
Then  the  soft  palate  is  divided  on  one  side  of  the  uvula,  and  the 
esophagus  along  its  median  line  posteriorly  down  to  the  opening  into 
the  thorax.  All  parts  and  recesses  of  the  pharvngolaryngeal  mucous 
membrane  are  now  fully  exposed ;  the  tonsils  can  be  incised  ;  the  ary- 
epiglottic  folds  are  inspected  for  edema  or  wrinkling  due  to  a  more  or 
less  completely  subsided  edema ;  small  bodies  are  detected ;  and  the 
color  and  condition  of  the  mucous  membrane  in  general  are  ascertained. 
The  organs  of  the  neck  are  then  dropped  back  into  the  body,  and  the 
examination  of  the  thoracic  organs  is  commenced. 

The  Organs  of  the  Thorax. — Before  proceeding  to  examine  the 
lungs  and  the  heart,  the  condition  of  the  thymus  gland,  the  medias- 
tinum, the  contents  of  the  pleural  cavities,  as  well  as  the  condition  of 
the  pleura,  must  be  ascertained. 

The  Lungs. — When  adhesions  exist  betw^een  the  parietal  and 
visceral  pleurae,  these  are  torn  with  the  fingers  or  cut  across  with  the 
knife ;  very  extensive  and  firm  adhesions  require  the  removal  of  the 
parietal  pleura  with  the  lung,  w^hich  is  best  accomplished  by  blunt  dis- 
section M'ith  the  fingers,  separating  the  extraj)leural  cellular  tissue. 
Inseparable  adhesions  l)etween  the  lung  and  the  diaphragm  or  the  peri- 
cardium necessitate  the  cutting  loose  of  the  adherent  parts  of  these 
structures  and  their  removal  with  the  lung. 

After  completely  separating  all  adhesions,  the  lungs  may  be  removed 
entirely  by  cutting  across  the  bronchi  and  the  vessels  at  the  root  of 
each,  being  careful  not  to  wound  the  aorta  or  esophagus.  In  order  to 
incise  the  lungs,  each  is  placed  upon  its  diaphragmatic  surface,  the  root 
being  held  by  the  left  hand,  and  a  free  incision  made  from  base  to 
apex,  so  as  to  expose  the  largest  possible  extent  of  cut  surface. 

It  is  often  desirable  to  leave  the  lungs  attached  and  to  remove 
the  organs  of  the  neck  and  chest  in  foto  because  of  the  continuity  of 
the  structures  composing  them,  and  of  the  clearer  idea  thus  obtainable 
of  various  morbid  processes ;  the  heart,  however,  is  usually  separated 
in  order  better  to  examine  and  to  weigh  it.  In  this  case  the  lungs  are 
incised  in  the  followinsr  manner  : 

The  right  lung  is  brought  out,  placed  upon  the  right  chest-wall,  and 
held  with  the  left  hand  so  that  the  median  surface  presents.  An 
incision  is  then  made  with  the  brain  knife,  running  about  2  cm.  (0.79 
in.)  inside  the  anterior  margin,  and  extending  through  the  whole  lung 
to  its  posterior  surface,  where  enough  substance  is  left  intact  to  hold 
the  organ  together.  This  incision  divides  all  three  lobes  into  equal 
halves.  Further,  secondary  incisions  may  be  made  in  the  direction  of 
the  bronchial  branches.  The  left  lung  is  incised  in  the  same  manner, 
by  placing  it  upon  the  left  half  of  the  chest^wall,  and  holding  the  ante- 
rior margin  away  from  the  examiner  with  the  left  hand. 

The  pericardium  is  opened  by  a  small  incision  in  the  center  of  the 
anterior  surface,  a  small  fold  being  pinched  up  in  order  to  prevent 
injury  to  the  heart ;  this  incision  is  then  prolonged  downward  to  the 


EXAMINATION    OF    THE    BODY. 


45 


left  and  to  the  right,  and  upward  as  far  as  the  reflection  of  the  mem- 
brane upon  the  large  vessels;  the  contents  and  the  surface  of  the  sac 
are  now  examined.  In  case  circumscril)ed  adiiesions  exist,  they  are  to 
be  divided  with  the  knife  ;  if  the  cavity  l)e  completely  obliterated,  a 
separation  may  be  accomplished  by  bkmt  dissection  with  the  fingers  ; 
or  it  may  be  necessary,  in  some  cases,  to  remove  the  pericardium  with 
the  heart,  and  to  make  the  necessary  incisions  into  the  heart  cavities 
througii  the  pericardium  and  the  heart-wall  at  the  same  time. 

The  Heart. — This  can  l)e  examined  according  to  various  plans,  each 
of  which,  when  understood,  yields  satisfactory  resuhs,  the  fundamental 
principle  in  all  methods  being  that  each  step  in  the  procedure  nmst  not 
in    any   way   interfere   with    the    parts    that    remain   to   be  examined. 


Fig.  4.— Removal  of  the  heart. 


External  inspection  of  the  heart  reveals  its  position,  size,  and  form,  as 
well  as  the  condition  of  the  coronary  vessels.  A  marked  distention  of 
the  veins  upon  the  anterior  surface  of  the  heart  points  to  obstruction 
to  the  outflow  from  the  right  auricle,  and  is  consec[uently  observed  in 
cases  of  asphyxia. 

In  order  to  determine  the  amount  and  the  condition  of  the  blood 
contained  in  each,  the  various  chambers  of  the  heart  are  best  opened 
wliile  it  is  in  situ.  The  incisions  for  this  })urpose  are  made  in  such 
fixed  locations  as  to  serve  as  the  beginning  for  those  incisions  employed 
in  the  more  detailed  examination  after  its  removal.  In  order  to  deter- 
mine the  weight  of  the  heart  and  the  sufficiency  of  its  valves,  it  is 
always  best  to  remove  it,  although   many  pathologists  complete  their 


46       THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

examinatiou  of  the  organ  while  it  remains  in  situ — others  remove  it 
unopened. 

Place  the  left  hand  under  the  heart  and  draw  it  downward  and  to 
the  left,  so  as  to  be  able  to  make  an  incision  into  the  right  auricle, 
between  the  entrances  of  the  superior  and  the  inferior  vena  cava. 
Then  open  the  right  ventricle  by  an  incision  beginning  below  the 
circular  furrow,  and  running  downward  to  near  the  apex,  along  the 
right  margin  and  in  line  with  the  cut  made  into  the  auricle  ;  the  con- 
tents of  these  cavities  may  now  be  examined.  In  cases  of  sudden  death, 
especially  in  puerperal  women,  the  pulmonary  artery  should  be  opened 
in  situ,  in  order  to  determine  the  absence  or  presence  of  emboli. 


Fig.  5.— Opening  the  right  ventricle  by  cutting  along  the  interventricular  septum,  the  blunt 
point  of  the  scissors  projecting  from  the  pulmonary  aorta. 

To  incise  the  cavities  of  the  left  side,  grasp  the  heart  so  that  the 
fingers  of  the  left  hand  lie  upon  the  anterior  surface  and  the  thumb 
upon  the  posterior,  the  a)3ex  resting  in  the  hollow  of  the  hand.  Make 
an  incision  from  the  left  superior  pulmonary  vein  through  the  auricular 
wall  nearly  down  to  the  transverse  furrow,  and  then  another  into  the 
cavity  of  the  left  ventricle,  conuuencing  below  the  transverse  furrow 
and  extending  along  the  left  margin  down  to  the  apex.  The  contents 
of  these  cavities  are  now  removed  and  examined. 


EXAMINATION    OF    THE    BODY. 


47 


Next,  the  heart  is  removed  by  lifting  it  directly  upward  and  cutting 
successively  the  vessels  that  enter  and  leave  it,  as  near  to  the  j)eri- 
cardiuni  as  possible  (Fig.  4).  The  competency  of  the  semilunar  valves 
is  next  tested  with  water  ;  all  coagula  are  removed,  the  aorta  and  pul- 
monary artery  are  trimmed  down,  so  that  the  behavior  of  the  valves 
can  be  observed  as  the  water  is  jwured  into  the  vessels,  while  the  heart 
is  suspended  by  the  auricles  so  that  the  plane  of  the  orifices  is  hori- 
zontal. Competent  valves  meet  exactly  under  the  column  of  water, 
whereas  the  segments  of  incompetent  valves  fail  to  meet  and  allow 
the  water  to  trickle  awav. 

The  heart  is  now  opened  completely  by  passing  the  blunt  end  of  an 
enterotome  into  the  right  ventricle,  above  the  attachment  of  the  papil- 


FiG.  6.— Right  ventricle  laid  open,  as  shown  in  Fig.  5,  and  without  cutting  papillary  muscle 

attached  to  anterior  wall. 


lary  muscle  to  the  anterior  wall,  and  cutting  through  the  wall  as  much 
to  the  left  as  possible,  continuing  the  incision  out  througli  the  jnilmonary 
artery  (Fig.  5) ;  it  will  be  found  that  when  the  scissors  are  held  as  far  to 
the  left  as  the  septum  between  the  ventricle  permits,  the  division  will 
pass  between  two  valve  segments  without  injury  to  either  (Fig.  6). 

The  left  ventricle  is  opened  by  passing  the  enterotome  u])ward  into 
the  cavity  from  the  incision  alreadv  made,  cutting  along  the  interven- 
tricular septum  (Fig.  7),  and  then  between  tiie  pulmonary  artery  and 
the  auricle,  tiircjugh  the  aorta ;  one  of  the  aortic  segments  is  unavoid- 
ably cut  in  two  by  this  incision. 


48       THE    TECHXIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

The  auricles  may  be  opened  still  more  by  prolonging  the  incisions 
made  out  through  the  veins  on  each  side,  a  good  view  being  thus 
obtained  of  their  interior  and  also  of  the  auricular  aspect  of  the  mitral 
and  tricuspid  valves.  Finally,  the  original  incisions  into  the  auricles  and 
ventricles  on  each  side  may,  if  desirable,  be  united  by  cuts  that  divide 
the  mitral  and  tricuspid  rings  ;  but  these  cuts  may  spoil  the  characteris- 
tic appearance  of  stenosis  of  the  orifices,,  as  well  as  other  changes. 

When  it  is  desired  to  obtain  exact  measurements  of  the  size  of  the 
orifices  of  the  heart  by  means  of  graduated  cones,  the  foregoing  pro- 
cedures  are   so  modified  that  the  cones  are  inserted  into  the  orifices 


Fig.  7.— Opening  the  left  ventricle  by  cutting  along  the  interventricular  septum,  the  blunt  point 

of  the  scissors  projecting  from  the  aorta. 

before  the  incisions  described  have  divided  the  semilunar  and  auriculo- 
ventricular  rings ;  naturally,  these  cones  are  inserted  in  the  same 
direction  as  the  blood  current,  and  with  great  gentleness,  so  as  not 
to  detach  inflammatory  vegetations  and  thrombotic  deposits.  The 
diameter  of  the  mitral  and  tricuspid  orifices  is  often  estimated  by  care- 
fully inserting  the  fingers  from  the  auricular  aspect — in  the  adult  the 
mitral  normally  admits  three  finger-tips  ;  the  tricuspid,  four. 

Having  removed  and  opened  the  heart,  the  examiner  is  now  ready 
to  make  a  detailed  examination  of  all  its  parts.  The  valvular  and  the 
mural  endocardium  are  to  be  looked  over,  the  foramen  ovale  and  the 


EXAMIXATIOX    OF    THE    BODY.  49 

membranous  part  of  tlie  ventricular  septum  are  inspected,  the  size  of 
the  ventricles  as  to  the  depth  and  thickness  of  the  Mall  may  be 
measured,  while  the  weight  should  always  be  determined,  as  it  gives 
the  most  accurate  indication  of  absolute  increase  or  diminution  in  sub- 
stance. The  condition  of  the  coronary  orifices  in  the  t;ommencement 
of  the  aorta  must  be  investigated ;  these  orifices  may  be  seriously 
involved  in  the  sclerotic  changes  so  often  found  immediately  above 
the  aortic  valves.  In  all  cases  of  sudden  death  from  obscure  causes 
the  coronary  arteries  must  be  searched  for  arteriosclerotic  and  other 
changes,  and  for  this  purpose  they  are  cut  open  from  their  begiimiug 
in  the  aorta  to  the  smallest  branches.  In  the  event  of  doubtful 
ooronary  disease  and  secondary  myocardial  changes  microscopic  exam- 
ination may  show  astonishingly  extensive  lesions.  The  myocardium, 
especially  of  the  left  ventricle,  is  finally  exposed  by  a  number  of 
incisions,  either  parallel   with,  or  vertical  to,  the  surface  of  tlu^  heart. 

Having:  examined  the  luno-s  and  the  heart  whollv  or  partiallv  in 
situ,  the  remaining  thoracic  organs  and  the  organs  of  the  neck  are 
removed  in  toto.  The  left  hand  grasps  the  organs  of  the  neck  and 
pulls  them  downward,  the  right  and  left  subclavian  arteries  and  veins 
and  other  structures  are  cut  across  by  a  curved  incision  on  each  side  at 
the  superior  opening  of  the  chest,  and  the  cellular  tissue  between  the 
•esophagus  and  the  thoracic  aorta  and  the  spinal  column  ra])idly  sepa- 
rated as  far  as  the  diaphragm,  while  the  organs  are  drawn  downward. 
Then  the  esophagus  is  ligated  near  the  diaphragm  and  divided  above 
the  ligature,  at  which  time  the  aorta,  the  inferior  vena  cava,  and  the 
parietal  pericardium  are  also  cut  across.  The  organs  are  then  placed 
upon  a  tray,  the  esophagus  being  uppermost.  This  latter  is  then 
divided  along  the  posterior  wall,  in  continuation  of  the  incision  already 
made  into  it.  Turning  the  mass  around,  the  arch  of  the  aorta  and  its 
large  branches,  as  well  as  the  thoracic  aorta,  are  laid  open  ;  then  the 
trachea  is  opened  by  continuing  the  incision  already  made  into  it,  and 
this  opening  may  be  continued  into  the  right  bronchus  ;  but  in  order  to 
open  the  left  bronchus  the  aorta  must  first  be  freed  and  taken  out  of 
the  way. 

The  peribronchial  lymphatic  glands  are  also  to  be  incised,  and  their 
relation,  if  perchance  tuberculous,  to  adjacent  vessels  determined.  If 
necessarv,  the  lun&s  mav  be  detached  and  weighed.  In  the  case  of 
aneurysms  of  the  aorta,  tumors  and  other  swellings  of  the  mediastinum, 
caution  must  be  used  in  removing  the  organs  from  the  chest,  so  that 
instructive  specimens  are  not  marred  by  unskilful  dissection,  and  the 
relations  disturbed. 

The  Organs  of  the  Abdomen. — A  preliminary  insjiection  of  the 
abdominal  cavity  was  made  for  tlie  purjjose  of  orientation  immediately 
after  the  long  anterior  incision  ;  before  any  of  the  organs  are  removed, 
the  cavity  should  again  be  inspected  and  the  condition  of  the  peri- 
toneum  definitely  ascertained  in  all   its  details. 

The  Spleen. — This  is  grasped  with  the  left  hand  and  drawn   for- 
M'ard  from  its  position  behind  the  fimdus  of  the  stomach,  any  adhesions 
Vol.  I.— 4 


50      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

present  being  carefully  separated.  As  it  is  drawn  forward  the  gastro- 
splenic  omentum  is  brought  into  view,  and  any  gross  changes  in  the 
splenic  vessels,  the  presence  of  accessory  spleens,  etc.,  readily  observed. 
It  is  then  removed  by  cutting  across  the  structures  at  the  hilus,  weighed 
and  measured,  and  an  incision  made  along  the  outer  surface  from  the 
upper  to  the  lower  end,  additional  lamellations  being  made  if  necessary. 

The  region  of  the  gall=bladder  and  biliary  ducts  is  to  be  carefully 
inspected  for  adhesions,  fistulae,  and  other  changes.  In  case  jaundice 
exists,  the  patency  of  the  common  duct  is  tested  in  the  following 
manner  :  By  cutting  across  the  diaphragm  the  liver  is  allowed  to  fall 
into  the  chest  cavity,  so  as  to  bring  the  region  of  the  hepatoduodenal 
ligament  well  into  view ;  then  the  second  part  of  the  duodenum  is 
incised  along  its  anterior  surface  between  two  ligatures  placed  at  a 
liberal  distance  from  each  other,  and  the  exposed  mucous  membrane  is 
wiped  dry.  Now,  by  compressing  the  biliary  duct  with  the  fingers  and 
toward  the  intestine,  one  can  observe  whether  or  not  the  bile  can  be 
expressed,  and  also  its  condition  as  it  exudes  at  the  biliary  papilla, 
which  is  located  about  9  cm.  (3.5  in.)  from  the  pylorus.  Compression 
of  the  gall-bladder  itself  should  be  avoided  until  the  results  of  the  fore- 
going procedure  are  established.  The  portal  vein  can  also  be  examined 
at  this  time. 

Diseases  in  the  region  of  the  gall-bladder,  the  duodenum,  the 
pylorus,  and  the  pancreas  often  result  in  such  matting  together  and  in 
such  extensive  adhesions  that  it  may  be  necessary  to  remove  these 
organs  as  well  as  the  liver,  the  stomach,  and  perhaps  the  large  blood- 
vessels in  conjunction,  in  order  to  be  able  carefully  to  dissect  and 
examine  the  complicated  conditions  satisfactorily.  In  removing  such 
masses  it  is  necessary  first  to  inspect  the  conditions  in  situ,  and  also  to 
examine  the  surrounding  structures  that  are  liable  to  become  injured  or 
disturbed  during  the  removal,  such  as  the  right  kidney  and  adrenal ; 
hence  such  removals  en  masse  are  to  be  postponed  until  the  examina- 
tion of  the  abdomen  is  completed. 

In  cases  of  hemorrhagic  and  other  forms  of  pancreatitis,  with  or 
without  disseminated  fat  necrosis,  the  diverticulum  of  Vater  and  the 
ducts  that  empty  into  it  should  be  carefully  examined  for  calculi,  for 
Opie  has  shown  that  their  lodgement  in  the  diverticulum  may  lead  to 
the  regurgitation  of  bile  into  the  pancreatic  ducts. 

The  liver  and  the  gall=bladder  are  removed  under  ordinary  condi- 
tions by  lifting  the  liver  u]>  with  the  left  hand  grasping  its  lower 
margin,  and  then  severing  the  hepatoduodenal  ligament,  observing  at 
the  same  time  the  cross-section  of  the  blood-vessels  and  duct  which 
it  contains,  the  ascending  vena  cava,  the  suspensory  and  the  coronary 
ligaments,  and  the  cellular  tissue  between  the  right  adrenal  and  the 
liver.  In  case  firm  adhesions  exist  between  the  liver  and  the  dia- 
phragm, the  corresponding  parts  of  the  latter  may  be  removed  with 
the  liver.  It  is  then  ])laced  on  its  anterior  surfiice,  and  the  exterior 
and  interior  of  the  gall-bladder  examined.  The  gall-bladder  is  opened 
by  a  longitudinal  incision  while  attached  to  the  liver,  or  it  may  be 


EXAMINATION    OF    THE    BODY.  51 

freed  bv  dissection  and  incised  by  itself.  Tlie  larger  branches  of  the 
portal  vein  and  the  i)art  of  the  inferior  vena  cava  usually  removed 
with  the  liver  are  to  be  laid  open.  The  liver  is  then  weiglied  ;uid 
measured,  and  its  interior  exposed  by  a  lon^:  incision  passing  trans- 
versely through  the  center  of  the  right  and  the  left  lobe  ;  additional 
transverse  incisions  may  be   made  parallel  to  the  first. 

The  kidneys  and  adrenals  are  best  examined  in  the  following 
manner :  Beginning  with  the  left  side,  the  sigmoid  mesocolon  is  divided 
near  the  intestine,  which  is  placed  on  the  stretch  by  the  left  hand  and 
drawn  over  to  the  right,  so  that  the  left  kidney  and  adrenal  are  fully 
uncovered  ;  by  a  little  dissection  the  beginning  of  the  ureter  and  the 
renal  vessels  are  exposed,  so  that  cognizance  may  be  taken  of  any  gross 
anomalies  or  morbid  changes.  Then  the  kidney  is  loosened  from  its 
bed  by  passing  the  left  hand  underneath  it  from  the  outside  and  from 
below  upward,  aided  by  the  knife  if  necessary.  In  order  to  remove 
the  adrenal  with  the  kidney  it  must  be  dissected  free  from  its  loose 
investment  before  the  kidney  is  lifted  out  of  the  body,  and  as  the 
adrenals,  especially  in  the  old,  are  very  friable,  they  must  be  handled 
gently.  As  the  kidney  is  lifted  out  of  the  body  the  vessels  are  cut 
across,  but  the  ureter  should  remain  attached. 

The  right  kidney  is  removed  in  the  same  general  way  ;  the  cecum 
and  ascending  colon  are  loosened  and  crowded  over  to  the  left,  the 
vessels  and  the  ureter  exposed,  and  the  kidney  and  adrenal  separated 
from  their  investments  and  lifted  out  of  the  body,  the  vessels,  in  the 
ordinary  case,  being  divided  while  the  ureter  remains  connected  with 
the  renal  pelvis.  The  ureters  are  readily  isolated  down  to  their 
entrance  into  the  bladder  by  means  of  careful  traction,  aided  by  a  little 
blunt  dissection. 

In  case  of  acquired  or  congenital  malposition  of  the  kidneys  it  may 
be  necessary  to  deviate  from  this  method,  because  in  floating  kidney  the 
great  lengthening  of  the  vessels,  and  in  the  instances  of  congenitally 
fixed  dislocations,  with  or  without  fusion,  the  atypical  origin  and 
number  of  the  vessels  may  require  a  more  extensive  and  painstaking 
dissection,  preceding  which  the  intestines  had  better  be  removed. 

In  the  routine  case  the  adrenals  are  next  detached  from  the  kidneys, 
weighed,  and  measured  ;  and  then  incised  in  the  longest  diameter  in  a 
sagittal  direction.  Then  each  kidney  is  measured  and  divided  into  two 
equal  longitudinal  halves  l)y  an  incision  from  the  convex  margin  to  the 
pelvis.  The  kidney  is  held  firmly  in  the  left  hand,  with  the  hilus  in 
the  angle  between  the  thumb  and  the  fingers,  the  thumb  being  ap])lied 
to  one  surface  and  the  fingers  to  the  ojiposite  aspect,  and  with  one 
stroke  of  the  long  knife  the  division  is  made  from  end  to  end  and  down 
to  the  hilus  ;  in  this  manner  the  kidney  is  divided  into  an  anterior  and 
a  posterior  half  at  the  same  time  that  the  calices  and  ])elvis  are  laid 
open.  This  division  should  be  a  perfectly  median  one,  otherwise  the 
pelvis  and  calices  are  not  clearly  dis])layed.  The  fibrous  capsule  of 
the  kidnev  is  now  detached  by  ])inching  up  the  cut  margin  of  the  latter 
at  the  convex  border  of  the  kidney,  and  stripping  it  oti'  from  the  sur- 


52       THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

face  ;  when  the  capsule  is  thickened  and  adherent  as  a  result  of  chronic 
inflammation,  thin  layers  of  the  cortical  substance  are  brought  with  it. 
The  external  surface  of  the  organ  is  now  examined,  and  then  the  cut 
surface,  paying  particular  atteution  to  the  cortical  markings  and  the 
relative  thickness  of  the  cortex  and  the  medulla.  Normally  the  thick- 
ness of  the  cortex  to  that  of  the  medulla  is  as  1  to  3,  the  measurement 
being  taken  from  the  apex  of  a  medullary  pyramid  to  the  surface  of 
the  kidney,  bisected  by  median  division.  Finally,  the  mucous  mem- 
brane of  the  pelvis  is  examined  and,  with  probe-pointed  scissors,  the 
ureters  laid  open,  from  the  pelvis  to  their  entrance  into  the  bladder. 
If  it  be  found  there  are  no  anomalies,  ascending  or  descending  inflamma- 
tions, or  dilatations,  which  are  best  studied  when  the  urinary  passages 
remain  continuous,  then  the  ureters  may  be  cut  across  and  the  total 
weight  of  the  kidneys  ascertained. 

The  pelvic  viscera,  including  the  bladder,  urethra,  the  sexual 
apparatus,  and  the  rectum,  should  all  be  removed  together. 

In  case  it  is  necessary  to  examine  chemically  the  contents  of  the 
urinary  bladder,  this  may  be  evacuated  with  a  clean  metal  catheter ;  in 
the  case  of  obstruction  to  the  catheter,  the  bladder  may  be  evacuated 
by  way  of  a  small  incision  in  its  anterior  surface. 

The  rectum  is  separated  from  the  descending  colon  between  a 
double  ligature.  The  bladder  is  loosened  by  inserting  the  fingers 
between  the  parietal  peritoueum  and  the  posterior  surface  of  the 
symphysis  pubis ;  then  the  loose  retroperitoneal  connective  tissue  is 
gradually  separated  in  the  same  manner  on  each  side  from  the  inner 
pelvic  wall,  so  that  the  hand  can  be  passed  all  around  the  pelvic 
organs  and  behind  the  rectum.  The  thighs  are  now  forcibly  adducted, 
and  while  the  external  genitalia  are  grasped  and  }>ulled  downward  with 
the  left  hand,  a  curved  incision  is  made  through  the  skin  at  the  root  of 
the  penis,  respectively  clitoris,  and  the  ligamentous  structures  and  the 
attachments  of  the  corpora  cavernosa  divided  close  to  the  pubic  arch, 
until  the  laiife  freely  enters  the  pelvic  cavity.  Then  the  opening  is 
enlarged,  and  the  left  hand  grasps  the  external  genitalia  from  within 
the  pelvis,  into  which  they  are  drawn  underneath  the  pubic  arch,  while 
curved  cuts,  meeting  behind  the  anus,  are  made  through  the  skin  on 
each  side,  and  the  muscular  and  fibrous  tissues  on  each  side  and  behind 
the  rectum  divided  until  all  the  attachments  of  the  organs  to  the  pelvis 
are  freed.  The  pelvic  organs  are  finally  lifted  up,  and  the  parietal 
peritoneum  divided  on  a  level  with  the  promontory  of  the  sacrum. 

If  the  kidneys  have  been  allowed  to  remain  connected,  the  examiner 
now  has  before  him  the  whole  urinary  tract  in  continuity,  as  well  as,  in 
women,  the  whole,  and  in  men  practically  the  whole,  genital  tract,  and 
also  the  rectum.  By  a  little  modification  of  this  procedure  the  vasa 
deferentia  and  the  testicles  may  be  isolated  and  guarded  from  separa- 
tion during  the  removal  of  the  pelvic  organs,  which  would  be  a  Avise 
plan  in  cases  of  extensive  urinary  tuberculosis. 

In  men  the  further  examination  consists  in  opening  the  bladder 
along  the  middle  of  its  anterior  wall,  and  from  this  incision  the  ante- 


EXAMINATION    OF    THE    BODY.  53 

rior  wall  of  the  urethra  is  incised  hy  means  of  probe-pointed  or  small 
intestinal  scissors  while  the  penis  is  held  on  the  stretch,  so  that  the 
incision  does  not  invalichite  the  posterior  wall  and  thus  uvutilate  the 
preparation.  The  mucous  membrane  of  the  bladder  and  urethra  is 
now  fully  exposed  for  examination. 

The  testicles  are  bisected  in  such  a  manner  as  to  include  in  the 
median  incision  the  head  of  the  epididymis. 

Now,  the  rectum  is  separated  from  the  bladder  and  tlie  prostate  by 
means  of  a  careful  dissection  carried  along  by  small  cuts  in  the  external 
layers  of  the  wall  of  the  rectum,  beginning;  in  the  Hoor  of  the  recto- 
vesical fossa,  while  the  structures  are  made  tense  by  traction  on  the 
bladder  in  one  direction  and  on  the  rectum  in  the  opposite.  The 
seminal  vesicles,  the  prostate,  and  Cowper's  glands  are  in  this  way 
made  accessible  to  a  satisfactory  examination. 

In  women  the  urinary  bladder  is  opened  from  the  urethra  ;  tlie 
vagina  and  the  uterus  are  divided  along  the  center  of  their  anterior 
walls  by  an  incision  which  divides  the  bladder  into  two  halves, 
unless  it  is  previously  loosened  and  laid  to  one  side  ;  or  the  vagina  and 
uterus  may  be  opened  along  the  posterior  wall  after  first  removing  the 
rectum.  At  the  upper  end  of,  and  at  right  angles  to,  the  .sagittal 
incision  into  the  uterus  two  shorter  cuts  are  made  toward  each  uterine 
opening  of  the  Fallopian  tubes.  Before  opening  tiie  uterus  the  appear- 
ance of  the  external  os  should  be  studied,  in  order  to  obtain  informa- 
tion as  regards  the  previous  occurrence,  or  not,  of  child-! )irth.  The 
size  of  the  uterine  vessels  and  the  thickness  of  their  walls  are  also  to 
be  noted,  and  in  the  puerperal  uterus  additional  incisions  into  the  wall, 
especially  at  the  placental  site,  may  be  necessary  in  order  to  determine 
the  condition  and  the  contents  of  the  vessels.  The  Fallopian  tubes  are 
cut  open  with  small  scissors,  the  ovaries  bisected  with  a  horizontal 
incision,  and  the  vessels  in  the  parametrium  and  the  broad  ligaments 
examined. 

Finally,  the  rectum  is  emptied  of  its  contents  by  means  of  a  stream 
of  water,  and  opened  with  the  enterotome  along  the  posterior  wall. 

When  external  conditions  prevent  the  removal  of  the  external  geni- 
tidia,  the  pelvic  organs  are  to  be  loosened  from  the  pelvis  as  before,  and 
drawn  firmly  toward  the  diaphragm  with  the  left  hand,  while  the  right 
divides  with  the  knife  the  urethra  as  far  as  possible  in  front  of  the  pros- 
tate gland  in  men,  the  vagina  at  its  middle  in  women,  and  the  rectum  as 
low  down  as  possible ;  the  organs  are  then  examined  as  before. 

The  stomach  and  duodenum  may  be  examined  in  situ  by  making 
an  incision  with  the  enterotome,  or  by  continuing  the  incision  eventually 
already  made  into  the  duodenum  in  examining  the  patency  of  the  bile- 
ducts,  from  the  pylorus  along  in  the  anterior  wall,  a  little  below  and 
parallel  with  the  lesser  curvature  and  out  through  the  part  of  the 
esophagus  that  still  remains.  Care  should  be  taken  to  empty  the 
stomach  before  the  incision  becomes  so  large  that  the  contents  cannot 
be  retained  bv  holding  up  the  margins  of  the  o])cuing.  Sinudtaneously 
the  duodenum,  or  that  part  not  already  exposed,  may  be  examined  by 


54      THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

cutting  it  open  with  the  enterotorae,  the  hepatic  flexure  of  the  colon, 
and  the  transverse  colon  being  first  loosened  and  turned  downward. 

In  the  majority  of  medicolegal  cases,  and  especially  when  poisoning 
is  not  definitely  excluded  from  the  start,  the  stomach  and  duodenum 
are  to  be  removed  unopened  from  the  body.  A  ligature  is  placed 
around  the  lower  end  of  the  esophagus,  the  diaphragm  being  divided  so 
as  to  expose  this  part  of  the  esophagus  freely,  and  then  the  attach- 
ments along  the  lesser  and  greater  curvatures  are  divided,  the  duo- 
denum is  dissected  loose,  and  a  double  ligature  placed  securely  at  its 
lower  end,  between  which  it  is  then  cut  across.  After  emptying  tlie 
contents  into  a  suitable  jar,  the  organs  may  be  incised  as  above  and  the 
mucous  membrane  examined. 

The  Pancreas. — This  is  exposed  by  dividing  the  insertion  of  the 
great  omentum  to  the  larger  curvature  of  the  stomach,  and  then  sepa- 
rating the  transverse  colon  and  the  stomach.  The  pancreas  may  be 
incised  along  its  greater  diameter  while  in  situ,  or  dissected  loose  from 
its  attachments,  care  being  exercised  that  pathologic  conditions  con- 
nected with  its  duct,  or  its  opening  thereof  into  the  duodenum,  are  not 
thereby  deranged. 

Diseases  such  as  cysts,  tumors,  abscesses,  fistulous  passages,  etc.,  in 
the  region  of  the  stomach,  duodenum,  pancreas,  gall-bladder,  and  liver, 
usually  require  the  removal  of  these  organs  en  masse,  in  order  to  clear 
up  the  conditions  by  a  careful  dissection. 

The  Intestines. — These  are  best  examined,  after  they  have  been 
carefully  inspected,  together  with  the  mesentery,  while  in  situ,  by  their 
complete  removal  from  the  body  and  their  opening  under  the  faucet  or 
under  water,  wliile  their  contents,  when  not  to  be  preserved,  are  allowed 
to  run  into  the  sewer  or  into  a  pail.  Grasp  the  lower  end  of  the  large 
intestine,  which  remains  ligated  from  the  time  the  rectum  was  removed, 
and,  making  it  tense,  sever  all  the  attachments  close  to  the  bowel. 
When  the  small  intestine  is  reached,  make  the  mesentery  tense  with  the 
left  hand,  which  lifts  the  bowel  up,  while  the  right  divides  the  mesen- 
tery very  close  to  the  bowel  by  means  of  an  almost  continuous  sawing 
motion  of  the  knife,  thus  allowing  the  intestinal  coils  to  straighten 
themselves  completely.  As  the  intestines  are  separated  they  are 
allowed  to  fall  either  into  a  pail  between  the  thighs  or  at  the  side  of 
the  body.  This  detachment  is  continued  up  to  the  duodenum,  where 
double  ligatures  are  placed,  if  this  has  not  already  been  done. 

The  small  intestine  is  opened  along  its  mesenteric  attachment, 
because  the  Peyer's  patches  are  situated  opposite  thereto  and  may  be 
the  seat  of  important  changes ;  the  opening  is  made  by  drawing  the 
intestine  through  a  partially  opened  enterotome  held  in  the  right  hand, 
the  blunt  end,  which  passes  into  the  bowel,  being  held  down^^•ard ;  and 
as  this  process  continues,  the  open  part  spreads  itself  out  over  the 
fingers  of  the  left  hand,  allowing  one  to  inspect  the  contents  and 
mucous  membrane  at  the  same  time. 

Wlien  the  intestine,  not  yet  incised,  becomes  coiled  and  twisted,  it 
is  straightened  out  by  lifting  the  part  being  cut  high  in  the  air,  pro- 


EXAMINATION    OF    TUE    BODY.  55 

t 

vided  it  has  been  separated  near  or  at  the  mesenteric  attachment. 
AVhenever  necessary,  one  may  wash  off  the  mucous  membrane  in  order 
to  remove  the  contents  suffi(!iently.  When  the  contents  are  to  be  saved, 
they  are  emptied  into  a  suitable  bottle  or  jar  by  removing  a  ligature 
before  incising  the  intestine ;  if  it  be  necessary  to  examine  the  contents 
of  difterent  parts,  then  such  })arts  are  separately  ligated  and  the  con- 
tents emptied  into  different  bottles. 

The  large  intestine  is  incised  in  the  same  way,  along  one  of  the 
three  longitudinal  bands  or  teniae,  and  emptied  of  its  contents  so  as  to 
expose  the  mucous  membrane. 

The  intestines  may  also  be  opened  and  examined  in  situ:  Beginning 
immediately  above  the  ileocecal  valve  the  small  intestine  is  incised 
with  the  enterotome  upon  its  under  surface  near  the  mesenteric  attach- 
ment. As  the  left  hand  turns  the  coils  upward  so  as  to  present  the 
under  surface,  this  incision  is  carried  along  step  by  step  up  to  the 
duodenum,  the  mucous  membrane  being  examined  as  the  bowel  is  laid 
open.  When  examination  of  the  small  intestine  is  finished,  the  large 
intestine  is  cut  open  from  the  ileocecal  valve  downward  along  the 
anterior  longitudinal  band. 

The  retroperitoneal  structures,  such  as  the  nerve  plexuses,  the 
aorta,  the  vena  cava,  and  the  retroperitoneal  lymphatic  glands,  are 
made  accessible  by  cutting  the  mesentery  across  at  its  root,  splitting 
the  large  vessels  open,  and  isolating  the  nerve  plexuses  and  semilunar 
ganglia  by  careful  dissection. 

The  diaphragm,  the  anterior  surface  of  the  spinal  column,  and  the 
pelvis  are  now  also  open  to  inspection.  The  various  pelvic  diameters 
may  be  determined,  and  the  form  of  the  pelvis  studied. 

The  Extremities. — In  the  extremities  the  blood-vessels,  nerves, 
lymph-glands,  lym})h-vessels,  muscles,  bones,  and  joints  may  require 
examination  in  special  cases.  The  location  and  course  of  the  incisions 
employed  for  the  purpose  of  exposing  or  isolating  any  of  these  struct- 
ures are  determined  by  the  anatomic  conditions ;  in  some  cases  the 
examiner  may  feel  it  necessary  to  conceal  the  cuts  as  much  as  possible. 
The  joints  are  opened  by  the  familiar  incisions  used  in  exarticulations 
and  resection.  In  order  to  expose  the  bone-marrow  for  general  inspec- 
tion one  of  the  femurs  is  usually  removed  and  divided  longitudinally 
by  means  of  a  saw,  the  bone  being  held  in  a  vise.  In  rachitic  and 
syphilitic  children  the  lines  of  ossification  at  the  various  epiphyses  may 
show  characteristic  changes  from  the  normal  that  are  best  studied  upon 
longitudinal  section  of  the  bones. 

EXAMINATION   IN  CASES  OF  SUSPECTED  POISONING. 

In  order  to  preserve  the  organs  and  fluids  from  such  cases  in  proper 
condition  for  chemical  analysis  a  number  of  new,  glass-stoppered  jars 
and  bottles,  thoroughly  washed  and  rinsed  with  sulphuric  acid  and 
finally  with  distilled  water,  should  be  secured.  As  the  organs  are 
placed  in  the  jars  these  should  be  sealed  and  labeled.  If  they  can  be 
delivered  to  the  chemist  immediately,  then  it  is  unnecessary  to  add  any 


56       THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

alcohol ;  if  they  are  to  be  kept  for  a  time  or  sent  some  distance,  a 
sufficient  quantity  of  strong  alcohol  must  be  added.  A  quantity  of 
the  alcohol  used  is  to  be  poured  into  a  clean,  empty  bottle,  which  is 
then  sealed  and  labeled  and  sent  with  the  organs ;  this  is  done  in  order 
that  opportunity  be  given  for  examination  of  the  alcohol  alone,  as 
regards  the  absence  or  presence  of  poisons. 

While  such  organs  remain  in  the  care  of  the  examiner,  he  must  keep 
them  under  sealed  lock  and  key  so  that  he  can  swear,  if  necessary,  that 
no  poisons  were  added  or  the  material  tampered  with  while  under  his 
care.  Such  jars  should  be  delivered  only  to  some  properly  authorized 
person,  and  an  accurate  record  of  the  number,  contents,  the  seal,  and 
the  disposition  of  the  jars  and  bottles  should  be  made  at  the  delivery 
and  kept  for  future  use. 

What  organs  and  fluids  should  be  preserved  will  depend  largely  on 
circumstances.  The  stomach  and  intestines  with  their  contents,  the 
liver,  and  the  brain  should  always  be  preserved.  In  the  case  of  dif- 
fusible poisons — strychnin,  arsenic,  etc. — the  urine  should  be  drawn 
with  a  clean  catheter  into  a  new,  clean  bottle,  and,  in  addition  to  the 
stomach  and  intestines  with  their  contents,  every  internal  organ  and 
also  a  mass  of  muscular  tissue  and  a  large  piece  of  bone  should  be 
kept,  so  as  to  furnish  the  chemist  Avith  sufficient  material  to  make  the 
result  of  his  examination  as  positive  as  possible.  A  portion  of  the 
blood  should  be  kept  in  those  cases  in  which  the  spectrum  analysis  may 
be  expected  to  furnish  important  information.  In  cases  in  which  it  is 
known  or  supposed  that  the  poison  was  inhaled,  the  lungs  should  always 
be  sent  to  the  chemist,  because  it  is  possible,  for  instance,  to  recover 
chloroform  from  the  lungs  even  long  after  death.  Narcotic  or  convul- 
sive poisonings  may  be  simulated  by  uremia,  or  such  claims  may  be 
advanced,  and  in  cases  of  suspected  intoxication  of  this  nature  both 
kidneys  should  be  secured,  partly  for  chemical  and  partly  for  histologic 
examination  ;  for  the  latter  purpose  small  pieces  may  be  cut  out  and 
fixed  in  the  different  solutions  used. 

The  organs  and  tissues,  before  they  are  placed  in  the  jars,  are  sub- 
jected to  the  same  examination  as  under  ordinary  circumstances,  but 
much  caution  is  to  be  used  so  as  not  to  bring  them  in  contact  with 
possible  poisonous  substances. 

In  a  case  of  suspected  poisoning  the  examination  should  begin  with 
the  abdominal  cavity,  the  position  and  the  fulness,  color,  and  smell  of 
the  stomach  and  other  abdominal  organs  being  carefully  noted.  Then 
a  double  ligature  is  placed  around  the  lower  end  of  the  esophagus, 
immediately  above  its  junction  with  the  stomach  ;  the  duodenum  is  tied 
in  two  places,  the  ligatures  being  placed  at  a  safe  distance  from  each 
other  so  they  will  not  slip.  The  stomach  is  then  removed,  the  duodenal 
ligatures  cut,  and  the  end  of  the  duodenum  placed  in  a  wide  jar  and 
the  stomach  alloAved  to  emjity  itself. 

The  small  intestine  may  be  removed,  and  the  contents  emptied  into 
another  jar  or  bottle ;  the  large  intestine  may  be  treated  likewise. 

The  examination  of  the  digestive  tract  is  done  at  this  early  time  in 


EXAMINATION    OF    THE    BODY.  57 

order  to  avoid  admixture,  as  well  as  injury  to  the  stomach  aud  the 
intestines  during  the  course  of  the  autoi)sy. 

The  stomach  and  the  intestines  are  best  preserved  by  themselves, 
because  poison  may  cling  to  the  mucous  membrane.  As  to  the  other 
organs,  it  cannot  be  said  to  be  absolutely  necessary  to  preserve  each 
organ  or  set  of  organs  by  itself,  although  this  would  be  the  best  plan. 

In  case  trichinosis  is  suspected,  the  contents  of  the  uj)per  part  of  the 
small  intestine  must  be  subjected  to  careful  microscopic  examination, 
and  pieces  are  to  be  taken  from  the  iutercostid  and  cervical  muscles 
and  from  the  diaphragm. 

EXAMINATION  OF  NEW-BORN  CHILDREN. 

"  In  examining  the  bodies  of  new-born  children  we  may  have  to 

determine,  besides  the  ordinary  lesions  of  disease,  the  age  of  the  child, 

whether  it  was  born  alive,  how  long  it  has  been  dead,  what  was  the 

cause    of    death."       The    examination    consequently    requires    especial 

.attention  to  the  following  features  : 

I.  Inspection. — Inspection  of  the  new-born  takes  into  considera- 
tion a  numl)er  of  points  that  bear  directly  upon  the  age  of  the  child 
and  the  length  of  time  that  has  elapsed  since  its  birth. 

Tiie  following  table  shows  the  weight  and  the  length  of  the  fetus  at 
each  month  of  gestation  (von  Hecker) : 


Weight. 

L 

EN(JTH. 

Second  mon 

th  .    . 

.    .    .        4 

S'i»-  •    • 

.    .    2.5 

to    3 

cni.( 

1      to 

1.2  in 

Third 

.    .        5.2 

.    ,    7 

'•     9 

i  i 

2.7    " 

3.5  " 

Fourth 

.    .    .    120 

.      10 

"  17 

u 

.  4      " 
,    7.1  " 

f>.8  " 

Fifth 

.    .    .    284 

.    .  18 

"  27 

C( 

lo.f;  " 

Sixth 

.    .    .    634 

.    .  28 

"  34 

;  ( 

ai      " 

13.4  '' 

Seventh 

.    .    .  1218 

.    .  35 

"  38 

u 

'14      " 

15      " 

Eighth 

.    .    .  1549 

.    .  39 

"  41 

u 

[15.4  " 

li).l  " 

Ninth 

.    .    .  1971 

.    .  42 

"  44 

u 

^16.5  " 

17.3  " 

Tenth 

.    .    .  2334 

.    .  45 

"  47 

i  i 

'17.7  " 

18.5  " 

From  the  fifth  month  the  age  in  months  can  be  estimated  by  divid- 
ing the  length  in  centimeters  by  five.  The  pupillary  membrane  dis- 
appears in  the  eighth  month.  At  full  term  the  skin  is  quite  firm  and 
white ;  the  lanugo  is  found  chiefly  on  the  shoulders  ;  the  navel  is 
situated  a  little  below  the  center  of  the  body  ;  the  nasal  and  aural 
cartilages  are  quite  firm  ;  the  nails  reach  beyond  the  fingers'  ends,  but 
not  beyond  the  ends  of  the  toes  ;  the  labia  are  nearly  always  closed, 
and  both  testicles  should  occupy  the  scrotum. 

In  addition  to  determining  the  length,  the  weight,  and  other  points 
referred  to,  the  following  measurements  may  be  tiU<en.  At  term  the 
results  are  about  as  given  : 

The  length  of  the  hair 1.5  to    3  cm.  (  0.6  to    1.2  in. 

The  length  of  the  anterior  fontanel 2      "     2.5  "  (  0.8  "     1      " 

The  circumference  of  the  head 34      "44  "  (13.4  "  17.3  " 

Mento-occipital  diameter 33      "38  "  (13      "  15      " 

Fronto-occipital  diameter 41      "44  "  (16.1  "  17.3" 

Transverse  (parietal  eminence*)  diameter 19      "22  "  (   7.5  "     8.7  " 

Bitemporal  (lower  ends  of  coronal  sutures)  diameter  .    .    .      8  "  (3.2  in.). 

AVidth  of  shoulders 12  "  (4.8  "  ). 

Width  across  trochanters 9  "  (3.6  "    ). 


58       THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

At  this  time  it  is  most  convenient  to  speak  of  one  of  the  most 
reliable  signs  of  maternity — namely,  the  center  of  ossification  in  the 
lower  epiphysis  of  the  femur.  In  order  to  determine  this  center  the 
knee-joint  is  opened  by  a  transverse  or  horseshoe-shaped  incision  between 
the  patella,  and  the  soft  parts  are  dissected  away  from  the  lower  end  of 
the  femur ;  the  epiphyseal  cartilage  is  then  divided  from  below  into  thin 
transverse  slices  until  the  greatest  diameter  of  the  focus  of  ossification 
present  is  reached.  This  diameter  is  then  accurately  measured.  It  is 
necessary  to  divide  the  cartilage  transversely,  because  only  in  this  way 
is  the  greatest  diameter  encountered.  At  full  term  the  diameter  varies 
from  2  to  5  cm.   (0.8  to  2  in.) ;    the  center  is  not  present  until  the 


^P 

■49 

^M 

ji 

■>■ 

/3y    "^     3 

^^ 

r 

h 

^ 

^KL^^I^Sm 

Fig.  8.— Center  of  ossification  in  the  lower  femoral  epiphysis  at  term  (Bichat's  center). 


thirty-seventh  week  (Fig.  8).  In  still-born  children  the  line  of  ossifica- 
tion at  the  junction  of  the  epiphysis  with  the  shaft  of  one  or  more  long 
bones  must  be  examined  for  evidences  of  congenital  syphilitic  osteo- 
chondritis by  dividing  the  bone  longitudinally. 

After  birth  the  skin  soon  becomes  more  dense ;  on  the  second  or 
third  day  it  assumes  a  yellowish  tingle,  which  increases  to  the  fourth 
day.  The  umbilical  cord  soon  begins  to  shrivel ;  it  becomes  brownish 
red,  and  after  three  or  four  days  the  skin  around  its  insertion  becomes 
somewhat  red.  The  end  of  the  cord  should  be  closely  inspected  to  deter- 
mine whether  it  is  cut  or  torn.  A  partially  or  wholly  cicatrized  navel, 
or  redness,  swelling,  and  suppuration  about  the  insertion  of  the  still 
attached  cord,  is,  of  course,  an  absolute  proof  that  the  child  has  lived 
several  days  after  its  birth.  Finally,  the  whole  body  is  to  be  inspected 
for  marks   of   violence,   blood,   evidences  of   decomposition,   etc. ;    the 


EXAMINATION    OF    THE    BODY.  59 

orifices,   especially  the   mouth  mid  the  nose,  are  to  be  examined   for 
foreign   bodies. 

2.  The  Spinal  Canal. — In  ojuMiing  this  canal  the  arches  are  best 
cut  across  by  means  ot'  a  strong  pair  of  scissors. 

3.  The  Head. — Tlie  incision  and  deflection  of  the  soft  parts  are 
made  as  in  adults.  The  margins  of  the  bones  of  the  cranium  can  then 
be  separated  from  their  attachment  t(^  the  dura  as  follows  :  Make  a 
small  opening  in  the  center  of  the  anterior  fontanel,  and  incise  the 
superior  longitudinal  sinus ;  then  divide  the  dura  on  each  side  of 
the  sinus;  now  cut  through  the  dura  along  the  coronal  and  lambdoidal 
sutures  on  each  side,  carefully  avoiding  the  surface  of  the  brain  ;  the 
bones  of  the  skull  can  now  be  drawn  away  from  the  l)rain  and  cut 
through  across  the  greatest  circumference,  and  the  brain  removed  as  in 
the  adult.  On  account  of  the  extreme  softness  of  the  brain  in  children 
and  the  firmness  of  the  dural  adhesions  along  the  sutures  it  is  very 
difficult  to  succeed  in  removing  an  infant's  brain  without  some  injury. 
An  attempt  to  saw  through  the  calvaria  in  the  ordinary  manner  nearly 
always  results  in  injury  to  the  brain.  If  it  be  not  desired  to  remove 
the  l)rain  as  a  whole,  then  Griesinger's  method  of  sawing  through  the 
skull  and  the  brain  at  the  same  time  is  very  serviceable  ;  the  calvaria 
receives  the  upper  part  of  each  hemisphere,  and  the  rest  of  the  brain  is 
removed  as  in  the  adult. 

4.  The  Abdomen. — In  the  new-born  the  examination  of  the 
navel  and  of  the  umbilical  vessels  is  of  great  importance.  Nauwerck 
practises  the  following  modification  of  the  ordinary  method  :  The  usual 
incision  is  made  from  the  chin  downward  to  a  short  distance  above  the 
umbilicus,  where  this  incision  divides,  as  it  were,  into  two  diverging 
incisions  that  extend  to  the  pubes ;  the  abdomen  is  opened  along  the 
lines  thus  mapped  out,  and  the  triangular  flap  in  the  abdominal  wall  is 
raised  up  by  traction  on  the  cord  or  the  navel.  This  makes  the 
umbilical  vein  prominent.  By  dividing  the  vein,  after  having  ojicned 
and  examined  it,  the  flap  is  turned  down  over  the  pubes,  and  the 
umbilical  arteries  are  seen  on  each  side  of  the  urachal  remnants  and 
may  be  examined  ;  or  one  may  make  the  usual  incision  to  the  left  of  the 
navel  and  then  excise  the  navel  by  a  cut  around  its  right  aspect,  sever- 
ing the  umlnlical  vein  and  arteries,  and  then  examine  these  structures 
and  their  contents  l:)y  means  of  successive  transverse  incisions. 

5.  The  Thorax. — The  ductus  arteriosus  is  best  examined  in 
situ:  the  thymus  gland  is  removed;  the  right  ventricle  is  incised 
along  the  interventricular  septum,  and  the  cut  continued  along  the 
middle  of  the  anterior  wall  of  the  ]iulmonary  artery  ;  the  orifice  of  the 
ductus  arteriosus  will  be  found  midway  between  and  beyond  the  two 
openings  of  the  right  and  the  left  pulmonary  branch,  and  a  small  probe 
may  be  passed  through  the  duct  downward  and  a  little  to  the  left  into 
the  aorta. 

In  order  to  determine  whether  or  not  respiration  has  taken  ])lace, 
the  following  procedure  is  practised  :  The  height  of  tiie  diajihragm  is 
determined  before  the  chest  is  opened  (when  respiration  has  fully  taken 


GO       THE    TECHNIC    OF    MEDICOLEGAL    POSTMORTEM    EXAMINATION. 

place  the  diaphragm  reaches  to  the  fifth  or  the  sixth  rib  ;  otherwise  only 
to  the  fourth) ;  the  trachea  is  ligated  in  the  neck  before  opening  the 
chest ;  then  the  chest  is  opened,  and  the  pleurae,  pericardium,  and  heart 
are  examined ;  the  pharynx,  larynx,  and  trachea,  above  the  ligature, 
are  also  opened  and  examined.  The  organs  of  the  chest  are  now 
removed  in  toto,  the  trachea  being  divided  above  the  ligature,  the 
heart  and  the  thymus  gland  separated,  and  the  lungs  placed  in  a  basin 
of  cold,  clean  water.  In  case  they  float  freely,  respiration  has 
undoubtedly  taken  j^lace ;  if  the  lungs  sink,  then  the  test  is  not 
decisive.  The  limgs,  under  such  circumstances,  are  to  be  incised  and 
note  taken  as  to  whether  they  crepitate  or  not,  and  whether  air-bubbles 
appear  when  parts  are  compressed  below  the  surface  of  the  Avater. 
Furthermore,  the  lungs  must  be  separated  into  lobes,  the  lobes  into 
minute  pieces,  and  tlie  hydrostatic  test  again  applied.  In  this  M^ay  it 
may  be  possible  to  determine  that  air  has  gained  entrance  into  certain 
parts  of  the  lung  in  sufficient  quantity  to  prevent  small  pieces  from 
sinking. 

In  the  case  of  decomposition  and  the  possible  production  on  that 
account,  in  the  lungs,  of  sufficient  gas  to  buoy  them  up  in  the  water, 
then  a  number  of  small  pieces  from  the  lungs  are  to  be  placed  between 
the  folds  of  a  towel,  and  thoroughly  compressed  between  two  flat  sur- 
faces, such  as  between  the  floor  and  a  board,  exerting  pressure  by  stand- 
ing on  the  latter.  The  gas  due  to  decomposition  is  pressed  out,  and 
the  pieces  from  atelectatic,  decomposed  lungs  M'ill  sink  when  throwTQ  in 
the  water  after  this  treatment ;  inspired  air,  on  the  other  hand,  cannot 
be  pressed  out,  and  the  pieces  from  inflated  lungs  continue  to  float. 

RESTORATION  OF  THE  BODY. 

Upon  the  completion  of  the  autopsy  the  body  is  to  be  placed  in  the 
most  presentable  condition  attainable  under  the  circumstances.  This 
much  is  imperatively  demanded  from  the  humanitarian  point  of  view. 
It  is  also  to  be  l)orne  in  mind  that  any  visible  disfigurement  of  corpses 
over  which  public  burial  rites  are  to  be  performed  would  not  tend  to 
predispose  the  laity  in  favor  of  granting  autopsies  on  patients  that  die 
in  private  or  liospital  practice.  Hence  the  incisions  should  be  so 
planned  that  their  location  is  not  conspicuous,  and  an  effort  should 
always  be  made  to  obliterate  all  evident  traces  of  the  autopsy,  so  that 
the  fact  that  the  bod}-  has  been  examined  can  be  recognized  only  after 
more  careful  observation  than  is  usually  given  dead  bodies. 

The  body  cavities  should  be  sponged  dry.  Such  organs  as  are  not 
taken  away  should  be  returned  to  their  respective  cavities.  The  l>rain 
would  better  l)e  placed  in  the  thorax  or  abdomen,  because  it  is  difficult 
to  force  it  back  into  the  cranial  cavity,  which  had  best  be  filled  with 
absorbent  cotton  or  sawdust  and  shavings  ("  excelsior  packing  "),  so  as 
to  prevent  bloody  fluid  from  oozing  out  through  the  incisions.  Inas- 
much as  decomposition  occurs  more  rapidlv  in  bodies  subject  to  post- 
mortem examination  it  is  well  to  fill  the  chest  aud  abdominal  cavities 


T^E>TOi;ATinX    OF    THE    BODY.  61 

also  with  absorbent  material,  in  the  siiinnier-time  especially.  Foul 
odors  may  be  prevented  by  dusting  the  interior  of  the  cavities  with 
some  deodorizing  and  disinfecting  powder.  AMien  the  mouth  has  been 
forced  open  and  the  tongue  removed  with  the  organs  of  the  neck,  the 
lips  may  be  united  by  a  suture  passed  througii  the  oral  mucous  mem- 
brane. The  incisions  at  the  pelvic  outlet  should  be  securely  sutiu'cd 
and  the  pelvis  packed  with  absorl)ent  material.  In  ihc  ])lace  of  bones 
that  have  been  removed  suitable  pieces  of  wood  can  be  inserted  and,  if 
necessary,  wired  in  place. 

It  is  advisable  to  secure  the  .-kull-caj)  in  its  normal  j)Osition,  so 
that  the  unsightly  disfigurement  which  results  from  its  sliding  back- 
ward and  from  side  to  side  may  be  avoided.  Sutm'es  through  the 
divided  temporal  muscles  and  fascia  on  each  side  generally  hold  the 
calvaria  nicely  if  passed  well  through  the  fascia ;  sntnres  can  also  be 
passed  through  drill-holes  in  the  skull ;  double-ended  tacks  may  also  be 
used  for  this  purpose.  After  securing  tlie  skull-cap  the  scalp  is  sutured 
with  the  glover's  stitch,  and  the  hair  arranged  so  as  to  cover  the 
incision. 

All  sutures  used  in  closing  cutaneous  postmortem  incisions  are 
passed  through  the  skin  Avith  a  good-sized  curved  needle,  and  each 
margin  of  the  incision  is  perforated  in  turn  from  within  outward,  so 
tliat  the  closure  can  be  made  quite  tight,  after  the  manner  of  the 
glover's  stitch. 


IDENTITY. 


General  Statement. — The  mutual  recognition  of  friends  who  are 
associated  at  frequent  intervals  is  a  matter  of  daily  occurrence  which 
excites  no  thought  of  the  principles  on  which  rests  an  establishment  of 
identity.  Friends  who  have  been  separated  for  years  usually  require 
nothing  more  than  a  glance  at  the  features  to  excite  recognition  and 
start  a  train  of  associations  long  since  passed  out  of  mind.  The  prin- 
ciple so  fundamentally  applied  by  Hume  is  here  the  basis  of  identifica- 
tion, for  we  know  by  experience  that  the  possibility  that  another  person, 
exactly  resembling  our  friend,  should  appear  under  such  circumstances 
need  never  be  considered.  If,  however,  the  period  of  association 
shortens,  or  if  the  character  of  the  association  has  been  entirely  com- 
monplace, or  if  the  separation  has  been  sufficiently  prolonged  to  allow 
the  changes  of  time  and  occupation  to  stamj)  tlie  features  and  estrange 
the  mind,  the  recognition,  even  of  former  close  friends,  frequently 
requires  the  overcoming  of  surprise  and  momentary  doubt.  Instances 
of  this  sort  are  not  infrequent  where  the  ordinary  changes  in  features, 
voice,  and  character  reduce  the  basis  of  the  recognition  of  friends  solely 
to  a  belief  in  their  verbal  statements.  The  unreliability  of  such  evi- 
dence, even  in  the  ordinary  affiiirs  of  life,  and  the  credulity  with  which 
the  average  man  accepts  such  imperfect  proof,  needs  no  clearer  comment 
than  the  endless  series  of  successful  "  confidence  games  "  reported  in  the 
daily  papers. 

A  distinctly  new  element  is  added  to  the  problem  when  it  is  required 
to  convince  a  third  person  of  the  identity  of  a  friend,  for  the  moment 
the  question  of  a  proof  of  such  identity  is  raised  by  the  third  person  a 
most  delicate  and  difficult  problem  arises  that  has  again  and  again 
taxed  the  finest  sagacity  of  both  lawyer  and  physician.  This  last  situa- 
tion always  exists  when  the  question  of  identity  is  brought  ])efore  a 
jury,  and  the  literature  of  legal  medicine  offers  many  famous  instances 
in  which  the  decision  turned,  often  in  an  extremely  dramatic  way,  upon 
the  identity  of  individuals.  It  might  be  anticipated,  from  the  indirect 
nature  of  conclusions  drawn  from  the  experience  of  the  senses,  and  from 
the  still  more  uncertain  character  of  personal  impressions,  that  mere 
verbal  statements,  in  the  absence  of  objective  proof,  are  of  little 
positive  value  in  deciding  questions  of  identity.  The  following  well- 
knoAvn  cases  may  serve  to  emphasize  the  unreliability  of  all  evidence 
based  upon  individual  belief  and  experience,  and  the  frequent  danger  of 
accepting  accidental  physical  resemblance  as  concrete  or  positive  proof 
of  identity. 

62 


GENERAL    STATEMENT.  63 

The  Tioliborne  case,  a  full  account  of  which  may  be  found  in  Guy's 
Forensic  Medicine,  page  680,  is  probably  the  most  instructive  illustra- 
tion of  the  foregoing  statements  yet  recorded.  A  man,  thought  to  be 
Arthur  Orton,  a  butelier's  son,  claimed  to  be  Sir  lloger  Tichbornc  and 
heir  to  the  baronetcy  and  estates  of  Sir  lioger,  who  was  believed  to 
have  perished  at  sea  many  years  before.  In  spite  of  the  most  striking 
dissimilarity  finally  demonstrated  between  this  man  and  the  real  Sir 
Roger,  the  impostor  Avas  accepted  by  a  score  of  witnesses,  including 
seventeen  servants,  the  family  solicitor,  and  even  by  the  mother  of  Sir 
Roger,  who  positively  identified  him  as  her  son.  It  was  only  when  the 
objective  points  in  the  stature,  features,  and  accidental  markings  of  the 
body,  as  well  as  the  mental  traits  of  Orton,  were  compared  with  those 
known  to  have  characterized  the  real  Roger  that  the  com})arative  worth- 
lessness  of  the  very  positive  impressions  of  the  friends  and  even  of  the 
mother's  instinct  was  established  and  the  impostor  detected. 

An  older,  and  in  some  respects  even  more  remarkable,  case  is  that 
of  Martin  Guerre.'  Guerre  had  been  away  from  home  for  eight  years 
and  was  presumably  dead,  when  one  Dutille,  who  nmst  have  shown  the 
clearest  possible  physical  resemblance  to  Guerre,  was  accepted  by  his 
wife,  and  assumed  control  of  tlie  property.  For  three  years  he  lived 
in  the  same  house  with  seven  relativ^es,  all  of  whom  failed  to  detect  the 
deception,  and  children  were  Ijorne  to  him  by  Guerre's  wife.  Finally 
Dutille's  worthless  character  began  to  assert  itself,  and  aroused  a  train 
of  suspicions  which  led  to  an  indictment  of  the  impostor.  The  legal 
inquiry,  however,  remained  doubtful,  or  favorable  to  the  impostor,  until 
the  real  Martin  Guerre  appeared  upon  the  scene,  completely  established 
his  own  identity,  and  secured  the  conviction  of  the  adventurer.  An 
examination  of  the  account  of  this  very  remarkable  case  not  only  dis- 
closes the  unreliability  of  individual  impressions  about  identity,  but 
also  in  a  startling  degree  illustrates  the  uncertainty  of  all  forms  of  evi- 
dence, even  of  the  most  objective  nature.  Not  only  was  Dutille's  claim 
actively  supported  by  Guerre's  wife  and  relatives,  but  he  showed  many 
of  the  physical  peculiarities  of  the  other,  such  as  scars  on  the  face,  a 
single  blood-shot  eye,  and  four  warts  at  identical  points  on  one  hand. 
His  mental  caliber  and  composition  were  somewhat  similar  to  Guerre's  ; 
he  accurately  recalled  many  of  the  early  experiences  of  Guerre,  and  even 
possessed  family  relics  known  to  have  been  carried  away  by  the  absent 
man. 

More  tragic  results  of  mistaken  identity  might  be  multi]ilied  at 
length,  for  legal  records  contain  at  least  several  undoubted  instances 
where  innocent  persons  were  executed  on  account  of  their  pronounced 
resemblance  to  the  real  culprits. 

Many  notable  errors  have  likewise  been  made  in  the  identification 
of  the  dead.  In  the  Edinhwr/h  3[o)dhhi  Journal  for  February,  18")4, 
Dr.  Hinloch  relates  a  case  of  mistaken  identity  under  the  following 
circumstances  :  The  body  of  an  old  man  was  found  on  the  bank  of  the 
Dee,  at  Drumoak.  The  left  ear  and  the  first  finger  of  the  left  hand 
'  Guy  and  Ferrier,  Principles  of  Forensic  Medicine^  p.  40. 


64  IDENTITY, 

were  wanting,  the  mutilation  apparently  of  long  standing.  Two  young 
women  claimed  the  body  as  that  of  their  father,  who  had  lost  his  left 
ear  and  left  forefinger,  and  who  had  been  in  the  habit  of  remaining  from 
home  for  weeks  at  a  time.  On  the  return  of  the  daughters  and  friend 
of  the  supposed  dead  man  fi'om  the  funeral  the  boatman  of  a  ferry 
which  they  had  to  cross  asked  them  for  whom  they  were  in  mourning, 
and  on  receiving  their  answer  laughingly  informed  them  that  he  had 
only  half  an  hour  before  ferried  their  father  over  alive  and  well,  which 
on  reaching  home  they  found  to  be  true.^ 

On  the  other  hand,  some  remarkable  successes  in  the  attempt  to 
reconstruct  and  identify  the  dead  body  from  mutilated  fragments  have 
been  recorded.  Of  these  may  here  be  mentioned  the  case  of  Dr.  Park- 
man,  whose  body  was  finally  and  positively  identified  by  the  absence 
of  teeth  in  a  fragment  of  the  lower  jaw,  and  that  of  JNIadam  Houet, 
whose  body  was  positively  identified,  and  even  the  manner  of  her  death, 
by  strangulation,  determined  eleven  years  after  l)urial. 

It  is  probable  that  cases  of  mistaken  identity  are  less  frequent  at  the 
present  day  than  forjuerly,  and  it  may  well  be  doubted  if  claims  such 
as  Orton's  could  be  maintained  with  so  much  strength  before  the 
present  courts.  Yet  recent  legal  records  are  by  no  means  lacking  in 
this  particular,  and  many  notable  trials  may  be  found  in  M"hich  a  wide 
variety  of  evidence  relating  to  identity  has  been  thoroughly  considered. 

A  recent  instance  in  which  an  experienced  detective  was  deceived 
in  the  matter  of  identity  is  quoted  by  Hamilton."  In  1887,  Mr.  A. 
Hedden,  of  Tacoma,  was  arrested  on  a  charge  of  defrauding  an 
insurance  company  out  of  a  large  sum  of  money.  He  had  been  mis- 
taken for  Mr.  A.  Crandall,  of  Buffalo,  by  Detective  Poyn,  of  Cincin- 
nati, who  based  his  identification  upon  similarity  in  stature,  features, 
color  of  eyes  and  hair,  and  especially  upon  the  presence  of  a  scar  on 
the  right  foot.  It  was  only  after  a  bitter  fight  and  the  presentation  of 
a  considerable  volume  of  evidence  that  Hedden  secured  his  liberty. 

A  very  instructive  case,  involving  a  great  variety  of  evidence,  is 
that  of  the  Bryant  estate.^  Here  the  decision  lay  between  five  sets  of 
claimants,  coming  from  four  different  States?*  of  the  Union,  as  well  as 
from  Nova  Scotia  and  England,  and  all  positively  identifying  the  dead 
man  as  their  relative.  The  decision  rested  largely  upon  the  contents 
of  a  trunk  owned  by  the  deceased,  which  contained  his  certificate  of 
citizenship  and  some  old  photographs,  all  of  which  were  held  by  the 
court  to  give  decisive  evidence. 

In  the  opinion  handed  down  by  Justice  Mitchell  are  these  significant 
statements  :  "  Identity  is  one  of  the  most  difficult  questions  with  which 
the  administration  of  justice  has  to  deal,  and  whether  the  witnesses 
have  seen  the  party  in  question  or  not,  their  testimony  as  to  recognition 
or  identification  is  one  of  the  least  reliable  facts." 

The  romantic  history  of  the  case  of  the  Shehan  estate  seems  well 
worthy  of  reference,  both  on  account  of  its  partial  resemblance  to  the 

^  Ogston,  Medical  Jurisptnidence,  p.  07.  ^  System  of  Legal  Medicine,  i.,  p.  201. 

'•>  176  Penna.,  p.  309,  1896." 


AGE.  65 

Tichborue  case,  in  that  the  niotlier's  instinct  was  j)roved  at  fanlt,  and 
also  as  representing  the  varied  ciiaracter  of  the  evidence  atitecting  identi- 
fication, and  the  positive  nature  of  the  proof  retpiired  to  establish  the 
identity  of  a  claimant  to  an  estate.  Here  the  chiiniant's  case  rested 
upon  the  presence  of  a  large  birthmark,  by  which,  j)rincij)ally,  the 
mother  recognized  the  claimant  as  her  child  ;  striking  resemblance  to 
the  father  in  person,  movement,  and  disposition  ;  and  the  early  recollec- 
tion by  the  claimant  of  a  man  whose  nose  had  been  destroyed  by  cancer, 
and  who  was  a  member  of  the  family  into  which  Siiehan's  child  had 
been  adopted.  A  full  report  of  the  history  of  tliis  case,  and  the  very 
able  summary  and  opinion  of  Judge  Hawkins  in  deciding  against  the 
claimant,  may  be  found  in  the  Pithburg  Legal  Joiinial,  May  21,  1890. 

The  important  rulings  in  the  al)ove  opinion  are  as  follows:  (1)  A 
elaimant  to  an  estate  must  not  only  make  out  a  prima  facie  case,  but 
must  sustain  it  by  weight  of  evidence  when  attacked.  (2)  Personal 
resemblance  by  claimant  t(j  decedent,  the  existence  of  a  birthmark  on 
the  claimant  corresponding  to  a  birthmark  on  decedent's  child,  and 
recofirnition  of  such  claimant  as  such  child  bv  the  mother,  will  not  of 
themselves  prove  identity,  although  they  may  become  important  facts 
in  the  proof. 

The  inconclusive  character  of  the  evidence  on  either  side  renders 
this  decision  one  of  the  most  difficidt  yet  recorded  concerning  the 
identity  of  individuals,  far  exceeding  that  of  the  Tichborne  case,  in 
which  the  falsity  of  the  impostor's  claims  was  fully  demonstrated. 

The  general  problem  of  personal  identity,  in  so  far  as  it  concerns 
legal  medicine,  consists  essentially  in  a  study  (jf  the  physical  character- 
istics of  the  l)ody.  In  the  case  of  the  living,  it  includes  also  an  exam- 
ination of  the  mind  and  memory  of  the  individual.  While  a  decision 
in  some  of  these  questions  requires  very  little  medical  knowledge, 
many  others  demand  a  minute  acc[uaintance  with  tlie  laws  of  ])athology, 
acquired  only  by  the  experienced  physician. 

The  study  of  the  physical  characteristics  of  the  individual  involves 
the  consideration  of  all  the  external  features  and  of  the  natural  and 
accidental  changes  that  may  affect  them,  while  in  the  case  of  the  dead 
body  it  requires  also  an  examination  of  tlie  viscera,  musculature,  and 
especially  the  skeleton. 

Age. — It  is  always  important,  in  the  attempt  to  establish  identity, 
to  determine  the  probable  age  of  the  individuah  The  means  at  our 
disposal  for  this  purpose  are  usually  greater  when  dealing  with  the  dead 
body,  and  the  fuller  discussion  of  this  subject  must  relate  almost 
exclusively  to  the  examination  of  the  cadaver.  Considerable  evi- 
dence, however,  some  of  which  is  ])eculiar,  can  be  elicited  by  an  exam- 
ination of  the  living  person.  One  cannot  do  more,  in  the  living, 
than  determine  the  age  within  certain  broad  limits — that  is,  it  can  be 
said  that  the  individual  is  in  the  period  of  infancy,  youth,  adolescence, 
old  age,  or  senilitv  ;  but  a  positive  opinion  cannot  usually  be  given  as 
to  the  exact  age  in  years  without  a  thorough  examination  of  viscera, 
musculature,  and  skeleton. 

Vol.  I.— 5 


66  IDENTITY. 

In  infancy  very  accurate  conclusions  may  sometimes  be  reached  by 
the  consideration  of  height,  weight,  number  and  condition  of  teeth, 
characters  of  the  fontanels,  and  general  development,  but  regard  must 
be  paid  to  possible  wide  variations  due  to  precocious  development  or 
to  disease.  Prolonged  malnutrition  and  congenital  syphilis  or  rachitis 
may  delay  infantile  development  considerably. 

In  youth  less  accurate  results  are  obtainable  from  physical  examina- 
tion, because  physical  changes  are  then  less  rapid  than  during  infancy. 
Here  the  height,  stature,  and  condition  of  the  teeth  are  investigated  as 
before,  and,  in  addition,  the  appearance  of  the  signs  of  puberty,  such  as 
chauges  in  the  voice  and  growth  of  hair,  may  give  important  indications. 

In  adult  life  it  is  very  difficult  or  impossible  to  determine  by 
physical  examination  the  aj^proximate  age  of  an  individual.  As  a 
result  of  personal  idiosyncrasy,  of  the  presence  of  a  youthful  type  of 
countenance  and  a  well-preserved  complexion,  and  with  a  strictly 
healthful  mode  of  life,  the  appearances  of  youth  may  be  long  retained 
or  the  approach  of  senile  changes  long  delayed.  On  the  other  hand,  a 
contrary  physical  idiosyncrasy,  an  elderly  type  of  countenance,  a  com- 
plexion affected  by  malnutrition,  mental  care,  or  dissipation,  premature 
baldness  or  the  sudden  appearance  of  gray  hair,  and  the  pronounced 
general  changes  due  to  arteriosclerosis,  may  have  an  influence  in  hasten- 
ing the  approach  of  the  signs  of  old  age  during  the  period  of  adult  life. 
Special  importance  here  attaches  to  the  early  onset  of  arteriosclerosis, 
which  may  attack  young  adults  and  has  been  observed  to  run  a  fatal 
course  even  in  youth.  Premature  baldness  may  occur  without  constitu- 
tional disease,  when  it  often  seems  to  show  hereditary  influence ;  or 
it  may  result  from  syphilis,  which  in  the  secondary  stage  produces  a 
circumscribed  temporary  alopecia,  and  in  the  tertiary  stage  often  a 
general  permanent  alopecia.^ 

In  old  age,  which  may  ordinarily  be  considered  to  begin  after  the 
sixtieth  year,  nearly  all  the  tissues  show  changes  which  are  in  them- 
selves cliai'acteristic,  but  of  which  the  onset,  as  stated,  may  be  consider- 
ably hastened  or  delayed.  As  a  result  largely  of  atrophy  of  the 
subcutaneous  adipose  tissue  the  face  loses  its  smooth  outlines  and 
usually  its  active  circulation  and  high  color.  Wrinkles  form  across  the 
forehead,  at  the  outer  angles  of  the  eyelids,  and  at  the  sides  of  the  nose, 
while  the  chin  becomes  more  prominent  and  the  features  and  expression 
become  more  fixed.  The  arcus  senilis  may  appear  in  the  cornea,  and 
the  eyesight  commonly  fails  perceptibly.  The  general  reduction  of  sub- 
cutaneous fat  produces  wrinkles  and  folds  on  the  hands  and  about  the 
axillse  and  groins,  and  a  sinking  of  the  pulp  of  the  thumbs.  In  Momen 
the  integument  of  the  abdomen  may  hang  in  large  loose  folds,  and  the 
mammse  are  reduced  in  size  and  may  become  pendant.  The  circulation 
is  enfeebled,  the  extremities  are  frequently  cold,  and  the  ready  response 
to  vasomotor  excitation,  as  seen  in  youth,  is  wanting.  The  arteries  are 
very  generally  found  in  some  degree  sclerosed. 

The  changes  in  the  bony  system  visible  externally  may  be  noted  in 
1  British  Medical  Journal,  1880,  pp.  114,  157,  197,  535. 


AGE.  67 

the  inferior  maxilla,  ^vllieIl  loses  its  marked  ano;ularity  and  suffers 
atrophy  at  the  points  where  teeth  have  been  lost.  The  neek  of  the 
femur  shortens  and  assumes  a  right  angle  with  the  shaft.  The  inter- 
vertebral cartilages  are  partially  atrophic,  causing  a  slight  loss  of 
motion  in  the  spinal  column.  This  anatomic  change  at  a  more 
advanced  stage  and  combined  with  loss  of  musculai*  tone  produces 
the  stooping  posture  and  irregular  gait  which,  with  gradual  failure  of 
mental  powers,  mark  the  period  of  senility. 

By  the  examination  of  the  dead  body  it  is  often  possible  to  deter- 
mine the  age  more  exactly  than  with  the  living.  This  greater  accuracy 
results  principally  from  the  information  derived  from  the  study  of  the 
bones  and  teeth.  The  degree  of  ossiiication  of  the  bones  furnishes  a 
very  reliable  guide  in  the  determination  of  age.  The  raj^d  changes 
occurring  in  early  life  in  this  and  other  tissues  permit  nuich  closer 
calculations  at  this  age  than  at  any  other  period.  l^arring  certain 
exceptions  to  be  attributed  to  rachitis  and  syphilis  in  youth,  and  to 
osteomalacia,  gout,  and  rheumatism  in  adult  life,  the  union  of  the 
various  epiphyses  of  the  long  bones  and  the  complete  ossification  of  tlie 
shafts  proceed  in  a  very  tmiform  sequence,  and  careful  observations  on 
the  condition  of  the  epiphyseal  lines  and  ossification  zones  in  the 
skeleton  are  the  chief  guides  in  determining  the  age  of  a  dead  body  or 
of  mutilated  remains.  For  complete  information  regarding  the  periods 
of  union  of  the  epiphyses  and  the  progress  of  ossification  the  reader 
may  refer  to  Qnain's  or  Gray's  Text-hook  of  Anaiomij.  The  following 
table,  compiled  from  Quain's  Anatomy,  gives  the  approximate  periods 
of  the  appearance  of  the  various  centers  of  ossification  and  of  the  union 
of  epiphyses  and  processes  : 

Periods  of  Union  of  Boxy  Epiphyses  and  Processes. 

First  Yew. — Laminae  of  some  vertebrae  ;  petromastoid  and  squam- 
ous portions  of  temporal ;  great  wings  and  liody  of  sphenoid. 

Second  Year. — Laminae  of  lower  sacral  vertebrae  ;  upper  and  con- 
dylar portions  of  occiput ;  frontal  suture  ;  lateral  halves  of  inferior 
maxilla. 

Third  Year. — Basilar  and  condylar  portions  of  occiput ;  fontanels 
nearly  closed. 

Fourth  Year. — Basi-occipitals  and  exoccipitals  ;  odontoid  process  of 
axis  ;  fontanels  closed. 

Sixth  Year. — Laminae  of  upper  sacral  vertebrae. 

Seventh  Year. — Rami  of  pul)es  and  ischium. 

Sixteenth  Year. — Lower  epi])liysis  of  humerus  ;  coracoid  process  of 
scapula. 

Seventeenth  Year. — Upper  epiphysis  of  radius  and  ulna ;  lesser 
trochanter. 

Eighteenth  Year. — Internal  condyle  of  humerus;  gn^ater  trochanter; 
head  of  femur  ;  lower  epiphysis  of  tibia. 

Twentieth  Year. — Greater  tuberosity  of  humerus ;  lower  epiphyses 
of  radius,  ulna,  femur,  and  fibula. 


68  .  IDENTITY. 

Eighteenth  to  Twentieth  Year. — Parts  of  acetabulum  ;  auricular  plates 
of  sacrum ;  sphenoid  and  basilar  portions  of  occiput. 

Twenty-first  Year. — Upper  epiphysis  of  tibia. 

Twenty-seeond  Year. — Acromion  and  scapula. 

Twenty-third  Year. — Tuberosity  of  ischium  ;  symphysis  pubis  ;  ante- 
rior inferior  spine  of  ilium. 

Twenty-fourth  Year. — Upper  epiphysis  of  fibula. 

Twenty-fifth  Year. — Heads  and  tuberosities  of  ribs  ;  sternal  epiphysis 
of  clavicle. 

Thirtieth  Year. — Three  coccygeal  vertebrae. 

Middle  Life. — Union  of  coccyx  and  sacrum ;  greater  cornua  and 
body  of  hyoid. 

Periods  of  Commencement  of  Centers  of  Ossification. 

Sixth  Month. — Manubrium  sterui. 

Seventh  Month. — First  segment  of  body  of  sternum ;  astragalus. 

Nintti  Mo)dh. — Lower  epiphyses  of  humerus  and  femur ;  upper 
epiphysis  of  tibia ;  cuboid ;  second  and  third  segments  of  body  of 
sternum  ;  hyoid  cornua  ;  first  coccygeal  vertebra. 

First  Year. — Coracoid  process  of  scapula ;  heads  of  humerus  and 
femur ;  lower  segment  of  body  of  sternum ;  os  magnum ;  external 
cuneiform  ;  anterior  arch  of  atlas. 

Second  Year. — Greater  tuberosity  and  lower  epiphysis  of  humerus  ; 
lower  epiphysis  of  radius  ;  upper  e])iphysis  of  fibula ;  patella ;  internal 
cuneiform. 

Fourth  Year. — Greater  trochanter  ;  lower  epiphysis  of  ulna  ;  scaphoid 
and  middle  cuneiform. 

Fifth  Year. — Lesser  tuberosity  of  humerus  ;  internal  condyle  of 
humerus  ;  upper  epiphysis  of  radius  ;  trapezium  ;  semilunar  ;  second 
coccygeal  vertebra. 

Sixth  Year. — Scaphoid. 

Seventh  Year. — Trapezoid. 

Tenth  Year. — Olecranon  process  of  ulna. 

Eleventh  Year. — Trochlear  portion  of  humerus. 

Twelfth  Year. — Pisiform  ;  cartilage  of  acetabulum. 

Thirteenth  Year. — Lesser  trochanter. 

Fourteenth  Year. — Acromion  process  of  scapula;  external  condyle 
of  humerus. 

Sixteenth  Year. — Inferior  angle  of  sea])ula. 

Eighteenth  Year. — Sternal  end  of  clavicle. 

After  the  thirtieth  year  the  advance  of  ossification  ceases  and  it 
becomes  impossible,  from  the  examination  of  the  skeleton,  to  determine 
within  narrow  limits  the  age  of  the  dead  body.  The  effects  of  increasing 
age  are,  however,  to  be  seen  in  certain  senile  changes  in  the  hones. 

Toward  the  close  of  adult  life  the  bones  become  brittle,  the  fatty 
marrow  is  more  abundant,  the  cancellous  spaces  may  contain  free  fat, 
the  lamellae  of  the  shafts  and  cancellous  tissue  are  partly  absorbed,  the 
cavities  are   larger,  and  the  bones  become  lighter  and   denser.     The 


AGE.  69 

cranial  sutures  become  completely  ossified,  immovable,  and  indistinct, 
altiiough  the  parietal  sutures  may  remain  separate  throu<!;hout  life.  "  If" 
tiie  sutures  of  the  skull  are  indistinct,  we  may  fix  the  age  between  fifty 
and  sixty  years"  (Tidy). 

The  gladiolus  and  xiphoid  ])ortions  of  the  sternum  usually  remain 
separate  until  the  thirty-fifth  or  the  fortieth  year,  while  the  manubrium 
and  gladiolus  are  not  united  until  advanced  age. 

In  adult  life  the  first  costal  cartilage  usually  becomes  surrounded  by 
a  superficial  layer  of  bone,  a  process  which  extends  slowly  and  with 
ffrcat  variations  over  the  other  costal  cartilatres.  These  bonv  changes 
in  the  ribs  are  usually  more  marked  in  men  than  in  women.  The  car- 
tilages of  the  larynx  become  ossified,  the  greater  cornu  of  the  hyoid 
bone  becomes  united  firmlv  to  the  bodv,  and  in  advanced  life  the  lesser 
cornu  may  also  be  united  to  the  body. 

Tiie  bodies  of  the  vertebne  are  beveled  on  their  anterior  edges,  pro- 
ducing a  moderate  kyphosis,  and  the  shrunken  intervertebral  disks  are 
very  flabby  and  inelastic. 

The  lower  jaw,  in  the  infant,  shows  a  shallow  body  with  the  mental 
foramen  near  the  lower  margin,  a  short  oblique  ramus  uniting  at  an 
obtuse  angle  with  the  body,  and  a  eoronoid  process  projecting  above  the 
condyle.  In  adult  life  the  l)ody  becomes  deeper,  thicker,  and  longer ; 
the  condyle  lengthens  and  projects  above  the  eoronoid  process,  and  the 
ramus  joins  the  body  at  nearly  a  right  angle.  In  old  age  the  loss  of 
teeth  causes  an  atrophy  of  the  alveolar  border ;  the  mental  foramen 
opens  in  this  border,  l)ut  the  angle  becomes  again  obtuse,  reverting  to 
the  infantile  type. 

Even  a  superficial  examination  of  the  skeleton,  with  attention  to 
those  of  the  mentioned  points  that  are  readily  accessible,  will  often  fix 
the  age  with  considerable  exactness,  while  bv  a  svstematic  studv  of  the 
bones,  although  at  the  expense  of  nuich  time  and  labor,  very  definite 
limits  can  be  given  in  almost  every  case. 

The  recent  investigations  of  Wachalz  '  on  the  dcter)/ii nation  of  age 
from  the  condition  of  the  upper  humeral  epijihysis  are  of  interest  in  this 
connection.  Wachalz  found  that  the  union  of  this  epiphysis  is  influenced 
by  the  sex,  the  nationality,  and  the  height  of  the  individual.  In  200 
cases  examined  the  cartilage  at  this  epiphysis  had  fully  disa])i)eared  in 
men  between  the  ages  of  twenty  and  twenty-one  years ;  in  women, 
between  the  ages  of  seventeen  and  eighteen  vears.  He  also  found  that 
the  development  of  the  marrow  cavity  in  the  shaft  of  the  humerus  is  a 
reliable  indication  of  age.  Between  the  thirtieth  and  the  thirty-fifth 
vcar  in  men  and  after  the  twcntv-eisrhtii  vear  in  women  the  medullarv 
cavity  extends  to  the  end  of  the  surgical  neck.  After  the  thirty-fifth 
year  in  men  and  a  little  earlier  in  women  it  is  found  up  to  the  epi])hy- 
seal  line.  The  full  development  of  the  medullary  cavity  is  retarded  in 
very  large  bones,  in  dwarfs,  or  after  wasting  diseases.  These  observa- 
tions were  substantiated  by  Preuss,^  who  found,  however,  that  the  bony 

'    Virchow's  Jahresbericht.  1893,  i..  p.  489. 
2  Ibid.,  1896,  i.,  p.  450. 


70 


IDENTITY. 


union  of  the  upper  humeral  epiphysis  was  not  complete  in  some  indi- 
viduals until  the  forty-fifth  or  forty-seventh  year. 

Some  features  of  the  skeleton  of  the  dwarf  are  well  illustrated  in  the 
description  of  a  case  by  Paltauf.^  The  subject  was  a  dwarf  of  forty- 
nine  years  of  age,  the  skeleton  resembling  in  many  respects  that  of' a 
child  of  seven  years.  The  epiphyses  of  the  long  bones  were  ummited 
and  the  synchondroses  were  still  loose.  The  spheno-occipital  synchon- 
drosis and  the  sutures  between  the  ilium,  pubes,  and  ischium  were  carti- 
laginous. The  diagnosis  of  an  adult  dwarfed  skeleton  was  possible 
from  the  condition  of  the  skull  and  cranial  sutures,  from  the  well- 
developed  ridges  at  the  insertions  of  muscles,  and  from  the  distinctly 
adult  form  of  the  inferior  maxilla. 

Race. — The  racial  characteristics  of  the  living  or  recently  dead 
body  are  readily  determinable  from  an  examination  of  the  skin,  hair, 
and  skull.     When  the  skeleton  alone  is  at  one's  disposal,  craniometry 


Fig.  9.— Side  view  of  skull  of  a  male  Australian :  a,  Alveolar  point ;  s,  subnasal  point ;  n,  na- 
sion ;  g^,  glabella:  op,  ophryon :  bg,  bregma;  06,  obelion  ;  I,  lambda;  o,  occipital  point:  i,  inion; 
6,  basion  ;  pt,  pterion  ;  .«<,  stephanibn  ;  as,  asterion ;  gl-o,  length  of  cranium  ;  b-n,  basinasal  length  ; 
h-a,  basi-alveolar  length  ;  n-s,  nasal  height. 

may  furnish  the  necessary  data.  The  important  features  to  be  noted 
in  distinguishing  skulls  of  diiFerent  races  are:  (1)  The  cranial  cavity  ; 
(2)  the  cranial  length,  breadth,  height,  and  circumference  ;  (3)  the  degree 
of  projection  of  the  jaws  ;   (4)  the  form  of  the  nasal  skeleton. 

The  cranial  capacity  is  found  by  filling  the  skull  with  shot,  of 
which  the  bulk  is  measured  in  another  vessel.  The  measurements  of 
the  skull  are  taken  from  points  located  in  the  accompanying  illustration. 

Tlie  circumference  of  the  cranium  is  taken  in  a  plane  passing 
through  the  ophryon  anteriorly,  and  the  occipital  point  posteriorly. 

The  length  of  the  cranium  is  measured  from  the  glabella  to  the 
occipital  point. 

^  Virchow's  Jahresbericht,  1891,  i.,  p.  511. 


RACE.  7 1 

Th(>   breadth   of  the  cranium    is  the  greatest  transverse  diameter 

above  the  snprainastoid  ridges.     The  proportion  of"  the  breadth  to  the 

,       ,,         100  breadth       ,        7,,   .    , 

length,  or  — , =:  breadth  index. 

^     '  length 

The  height  of  the  cranium  is  nieasnred  from  the  bunion  to  the 
bregma,  and  the  height  index  is  ealcnhited  in  the  same  way  as  the 
breadth  index. 

The  degree  of  projection  of  the  jaws  beyond  the  craninm,  or  gnathic 
index,  is  determinetl  by  (•()m])aring  the  bdsi-alveolar  length  with  the 
basinaml  length  {l)—a  :  b—n,  Fig.  9). 

An  important  characteristic  of  some  skulls  is  the  nasal  index — /.  e., 
the  relation  of  the  height  and  breadth  calculated  as  before.  The  height 
is  the  distance  from  the  nasion  to  the  subnasal  point  {n-s,  Fig.  9). 

In  the  European  the  plane  of  the  foramen  magnum  is  inclined 
upward  anteriorly.  In  the  Australian  and  negro  it  is  horizontal  or 
inclined  u])ward  j^osteriorly. 

The  pelvic  index — that  is,  the  relation  between  the  anteroposterior 
and  transverse  diameters  of  the  pelvic  brim — is,  according  to  Turner, 
characteristic  of  some  races. 

The  orbital  index  is  the  ratio  of  the  height  of  the  orbit  to  tlie  Avidth. 

The  craniometric  and  other  skeletal  indices  of  the  four  chief  races, 
as  compiled  from  Quain,  are  given  m  the  following  table  : 

CRANIAL   INDICES. 


Cranial  Capacity.      Breadth. 

Height. 

Orbital. 

Gnathic. 

Nasal. 

Pelvic  Index. 

English  .    .  1480  c.c.       76 

71 

88 

96 

46 

80 

Mesocephalic. 

Chinese  .    .  1430  c.c.       79 

75 

.Mesoseme. 

90 

Orthoiriiathous. 

99 

Leptorhinc. 

50 

Platvpellic. 

Mesocephalic. 

Negro     .    .  1350  c.c.       73 

72 

Megaseme. 

MesoKnathous. 

104 

Mesorhine. 

55 

93 

Dolichocephal 

Australian   1300  c.c.       71 

ic. 

71 

81 

Prognathous. 

104 

Plalvrhine. 

■57 

Mesopoliic. 

97 

Dolichocephal! 

,0. 

Microseme. 

Prognathous. 

Platyrhine. 

Dolichopellic. 

Other  important  racial  characteristics  relate  to  the  color  of  the  skin, 
the  hair,  the  orbits,  and  the  lips.  The  English  tyj)e  of  countenance 
needs  no  detailed  description  here.  The  Chinese,  Japanese,  and 
American  Indian  have  yellowish-broAvn  or  dark  reddish-l)rown  skin, 
straight  black  hair,  lips  and  orbital  ridges  not  prominent,  and  the 
countenance  peculiar  in  each  case. 

The  negro  has  coarse,  curly  or  woolly,  black  or  brown  hair,  dark  skin, 
protuberant  lips,  M'hile  the  orbital  ridges  are  not  prominent.  The 
Australian  has  black  "  frizzly  "  hair,  dark -brown  or  "  chocolate-colored  " 
skin,  pi'ominent  orbital  ridges,  and  thick,  protuberant  lips. 

When  any  of  these  races  intermarry,  the  offspring  seldom  ])resent 
the  racial  characters  of  either  parent  exclusively.  This  fact,  in  addi- 
tion to  the  great  range  of  individual  variation,  often  renders  the  deter- 
mination of  race  difficult  or  impossil)l('. 

Stature. — The  importance  of  tlie  stature  as  a  medicolegal  inquiiy 
has  long  l)een  recognized,  and  has  called  forth  much  careful  investiga- 
tion, with  the  result  that  several  systems  for  determining  the  height  of 


72 


IDENTITY. 


the  body  from  the  length  of  one  of  the  long  bones  have  been  proposed^ 
tested,  and,  for  the  most  part,  been  fomid  to  give  unreliable  results. 
J.  M.  Sue,  cited  by  Tidy,  more  than  a  century  ago  was  the  first  to  attempt 
to  calculate  the  total  length  of  bodies  from  that  of  the  trunk  or  extrem- 
ities. From  his  observations  it  appeared  that  from  the  twentieth  or  the 
twenty-fifth  year  until  old  age  the  symphysis  pubis  forms  the  exact 
center  of  the  body.  Orfila's  measurements  of  both  body  and  skeleton 
showed,  however,  that  J.  M.  Sue's  conclusions  could  not  be  trusted 
perfectly,  there  being  nearly  always  some  diiference  in  the  lengths 
above  and  below  the  symphysis  pubis.  He  oifers  other  tables,  based 
upon  the  length  of  the  separate  long  bones,  from  which  to  calculate  the 
total  height  of  the  body.  It  will  be  seen  in  these  tables  that  the 
possible  variations  are  so  great  that  the  average"  cannot  be  safely 
applied  to  individuals.  It  is  a  matter  of  common  observation  that  the 
length  of  the  limbs,  especially  of  the  arms,  may  be  entirely  dispropor- 
tionate to  that  of  the  body.  The  application  of  Orfila's  tables  is,  there- 
fore, to  be  made  with  great  caution. 


ORFILA'S   TABLES. 

Table  I. — Length  of  Body  calculated  frmn  Length  of  Long  Bones. 


Length  of  Bone. 

Inches. 

Maximum. 

Minimum. 

1 

Difference. 

Humerus,  19  observations  .    . 
Ulna,          14           " 
Femur,       12            " 
Tibia,          11 

14.5 
10.66 
17.75 
14.21 

68.1 
70.8 
69.66 
69.66 

64.5 
65.66 
64.0 
64.5 

3.6 
5.14 
5.16 
5.16 

Table  II. — Length  of 

Skeleton  calcu 

latedfrom  Length  of  Long 

Bones. 

Length  of  Bone. 

Inches. 

Maximum. 

Minimum. 

Difference. 

Humerus,  6  ob.servations.    .    . 
Ulna,         7            "           ... 
Femur,       7           "           ... 
Tibia,          7            "           ... 

13 

10.66 
18.1 
15 

73.25 
73.25 
72 
70.5 

69.75 
65 
67 
65 

3.5 
8.25 
5 
5.5 

Other  and  more  reliable  tables  have  been  prepared  by  the  later 
French  anatomi.sts,  Topinard  and  Rollet.  The  ratios  adopted  by 
Topinard'  are  as  follows:  Total  height,  100;  humerus,  20;  radius, 
14.3  ;  femur,  27.3  ;  tibia,  22.1.  To  the  height  tluis  calculated  must 
be  added  3.5  cm.  for  the  soft  parts.  Rollet,  after  comparing  the 
lengths  of  the  long  bones  with  the  lengths  of  50  male  and  30  female 
bodies  before  dissection,  deduced  several  methods  of  determining  the 
height  of  the  body,  according  to  the  shortest  of  which  the  total  height 
is  obtained  by  multiplying  the  length  of  the  male  humerus  by  5.06,  the 
female  by  5.22,  the  radius  by  6.86,  or  7.16,  the  femur  by  3.66,  or  3.71, 
the  tibia  by  4.53,  or  4.61. 

'  L' AnthTopologie,  1884. 


STATURE, 


Yo 


'  Dwiiilit '  has  studied  in  5()  male  and  21  female  subjects  the  relation 
of  the  length  of  the  body  to  that  of  the  spine,  exclusive  of  its  more 
variable  portions,  the  sacral  and  coccygeal.  These  ratios  were  found 
to  vary  with  the  length  of  the  s))ine  as  follows  : 

I  Females. 


Males. 
Length  of  Spine. 
Under  57 ('tn.  (22  in.)     .    .    .    . 
From  .J7  to  60  cin.  (22-24  in.). 
From  (JO  to  fi:3  cm.  (24-25  in.) . 


Katio.       Length  of  Spine.  Ratio. 

.  2.93  i  Under  54  cm.  (21  in.) 2.94 

.  2.84  I  From  .54  to  57  cm.  (21-22  in.)  ....  2.82 
.  2.7S    From  -57  to  GO  cm.  (22-24  in.)  ....  2.79 


From  63  to  66  cm.  (25-26  in.).   .    .    .2.7'.)    Above  60  cm.  (24  in.) 2.76 

Above  G6  cm.  (2(i  in.) 2.65  | 

The  practical  ajiplication  of  these  ratios  gave  specially  accurate 
results  in  the  case  of  female  subjects,  but  with  male  subjects  the  errors 
Avere  slightly  greater  than  those  usually  resulting  from  the  methods  of 
To])inard  and  Pollet.  In  Dwight's  experience  the  error  by  any  method 
is  likely  to  exceed  5  cm.  in  about  one-fourth  of  the  cases. 

According  to  Humphrey,  the  average  measurements  of  the  adult 
European  skeleton,  reduced  to  a  scale  of  100,  are  as  follows  :  Spine, 
34.15;  circumference  of  skull,  31.54;  length  of  humerus,  19.54; 
radius,  14,15  ;  hand,  11.23;  femur,  27.51  ;  tibia,  22.15;  foot,  10.03; 
transverse  pelvic  diameter,  8  ;  anteroposterior  pelvic  diameter,  6.0 1. 
These  figures  are  considerablv  at  variance  with  those  of  Orfila. 

The  following  table  of  Dr.  Guy's  was  compiled  from  his  observa- 
tions on  44  male  and  7  female  subjects,  with  full  appreciation  of  the 
inaccuracies  in  the  work  of  Sue  and  Orfila  : 


Sex. 

Stature. 

Vertex 

to 
pubes. 

Pubes  to 
foot. 

Upper  arm 

from 
acromion. 

Femur. 

Tibia. 

Fibula. 

Humerus. 

Radius. 

Ulna. 

Inches. 

Male. 

66.5 

33.5 

33 

29.5 

17.7 

14.6 

14.2 

12.4 

9.4 

10.2 

Female. 

61 

31.1 

29 

26.7 

16.5 

13.8 

13.4 

ll.G 

8.7 

9.8 

A  great  variety  of  rules  have  become  traditional  in  regard  to  the 
comparative  lengths  of  the  body  and  its  various  members,  all  of  M'hicli 
are  less  accurate  than  the  tables  of  Orfila,  Humphrey,  and  Guy. 

When  the  arm  alone  is  at  disposal,  the  a])proximate  height  is  said 
to  be  obtained  by  taking  twice  the  length  of  the  arm,  adding  10  inches 
for  the  two  clavicles  and  2  inches  for  the  sternum.  This  method  gives 
roughly  the  horizontal  reach  of  the  subject,  which,  however,  may  vary 
several  inches  from  the  height. 

When  the  hand  is  laid  flat  upon  a  table,  the  thumb-nail  is  usually 
on  a  line  with  the  web  of  the  middle  finger.  The  length  of  the  middle 
finger,  measured  from  this  line,  has  long  been  regarded  as  -^  of  the 
height  of  the  body.  The  length  of  the  forearm  from  the  tip  of  the 
olecranon  to  the  ti])  of  the  middle  finger  has  likewise  long  been  accepted 


as  measurmg  -f^  of  the  height  of  the  body 


1  New  Fork  Medical  Record,  1894,  p.  243. 


74  IDENTITY. 

In  the  Tichborne  case  the  question  was  raised  whether  Roger,  who 
at  twenty-one  years  of  age  was  slender,  5  feet  9|  inches  high,  and  9 
stone  in  weight,  with  narrow  hips,  thin,  straight  legs,  and  long,  bony 
fingers,  could,  after  twelve  years  of  active  life  in  Australia,  become  a 
huge  man  like  the  claimant,  Orton,  The  evident  improbability  of  such 
a  change  in  stature  bore  strongly  against  the  impostor.  Yet  considerable 
variation  in  the  weight  of  individuals  at  different  periods  of  life,  espe- 
cially of  women,  need  not  excite  surprise.  Recovery  from  an  acute 
infectious  disease  is  frequently  followed  by  increase  in  weight,  while  a 
chronic  disease  usually  reduces  the  weight.  Children  often  give  very 
early  indications  of  their  probable  adult  stature  and  weight,  but  severe 
rachitis  in  early  life  will  permanently  retard  the  best  development  of 
the  bony  skeleton.  The  effects  of  rachitis  on  the  adult  stature  are  very 
evident  in  the  poor  development  of  the  skeleton  and  the  bowed  limbs 
of  the  poorer  classes  of  Italians  in  this  country.  A  very  pronounced 
"■  pigeon-breast "  in  a  rachitic  infant  usually  leaves  demonstrable  traces 
throughout  life.  The  new-born  infiod  weighing  on  the  average  about  7 
})ounds,  loses  weight  rapidly  for  the  first  two  or  three  days,  to  the 
extent  of  from  4  to  7  ounces.  There  is  then  a  uniform  gain  in  weight, 
so  that  by  the  eighth  or  the  ninth  day  the  initial  loss  has  been  replaced. 
At  the  end  of  the  first  year  the  weight  is  nearly  tripled  ;  it  is  again 
doubled  by  the  sixth  year,  and  again  about  the  fourteenth  year. 

Sex. — The  sex  of  the  living  has  seldom  any  bearing  on  the  question 
of  identity.  AVhen  separate  portions  of  the  recently  dead  body  are 
recovered  there  is  usually  little  difficulty  in  discovering  the  sex  of  the 
individual.  When  the  head  only  is  found,  the  countenance,  skin,  and 
hair  will  generally  suffice  to  prove  the  sex.  In  the  trunk,  the  shape 
and  development  of  the  shoulders  and  chest  will  give  reliable  indica- 
tions in  the  absence  of  the  breasts,  uterus,  or  prostate  gland,  which 
ordinarily  serve  for  identification.  The  amount  of  hair  on  the  skin, 
the  formation  of  the  fingers,  toes,  and  nails,  the  thickness  of  subcuta- 
neous fat,  and  the  degree  of  muscular  development  are  to  be  considered 
in  the  limbs.  Rarely  is  it  possible  to  mistake  the  limb  of  a  hard- 
working woman  for  that  of  a  delicate  man. 

Between  the  skeletons  of  the  male  and  female  there  are  pro- 
nounced differences,  which  are  especially  evident  after  puberty.  In 
general  the  bones  of  the  female  are  lighter,  the  shafts  thinner,  the 
medullary  and  cancellous  spaces  relatively  wider,  than  in  the  male.  In 
consequence  of  slighter  muscular  development  the  bones  of  the  female 
are  less  curved,  the  processes  and  ridges  furnishing  ])oints  of  muscular 
attachment  less  prominent,  and  the  joints  smaller.  The  cranial  capacity 
of  the  average  female  is  about  one-tenth  less  than  that  of  the  average 
male,  and  the  frontal  and  occipital  regions  are  relatively  less  capacious. 

The  mastoid  processes,  superciliary  ridges,  zygomatic  arches,  and 
frontal  sinuses  are  less  prominent  in  the  female.  The  lower  jaw  is 
narrower,  the  chin  less  projecting,  and  the  face  smaller  in  proportion  to 
the  cranium  in  the  female.  The  female  thorax  is  relatively  shorter  and 
more  rounded  than  the  male,  but  the  spinal  column  and  trunk  are  rela- 


SEX. 


75 


tively  longer  in  the  female.      In   tlie  male  the  Ixxly  ol'  the  sternnm  is 
slightly  more  than   twice  the  length  of  the  manubrium,  while  in  the 


Fig.  10.— Male  pelvis  (slightly  less  than  one-third  natural  size)  (from  the  American  Text-Book  of 

Obstetrics). 

female  the  whole  bone  is  relatively  shorter  and  the  body  is  usually  less 
than  twice  the  length  of  the  manubrium.  The  ribs  are  smaller  and  the 
costal  cartilages  longer  in  the  female.  The  angle  lietween  the  neck  and 
shaft  of  the  femur  is  less  obtuse  in  the  female  than  in  the  male. 


Fig.  11.— Female  pelvis  (one-third  natural  size)  (from  the  American  Text-Book  of  Obstetrics). 

The  pelvis  of  the  two  sexes  differs  in  many  particulars.      "In  the 
female  the  height  is  less,  and  the  breadth  and  capacity  of  the  true  pelvis 


76  IDENTITY. 

greater ;  the  ilia  are,  however,  more  vertical,  and  thus  the  false  pelvis 
is  relatively  narrower  than  in  the  male  ;  the  inlet  of  the  true  pelvis  is 
more  regularly  oval,  the  sacral  promontory  projecting  less  into  it;  the 
sacrum  is  flatter  and  broader  ;  the  depth  of  the  symphysis  pubis  is  less  ; 
the  subpubic  arch  is  much  wider  and  the  space  between  the  tuberosi- 
ties of  the  ischia  greater "  (Quain).  The  accompanying  figures  illus- 
trate these  and  other  points  of  difference. 

Occupation. — As  many  of  the  trades  require  the  constant  use,  in 
the  same  manner,  of  a  single  instrument,  exercising  the  same  muscles, 
forcing  the  worker  to  use  the  same  special  senses  and  to  remain  long  in 
one  posture,  it  is  not  strange  that  many  tradesmen  carry  unmistakable 
physical  evidence  of  the  character  of  their  work.  These  marks  are 
naturally  found  in  the  members  most  severely  taxed,  as  in  the  hands  of 
day  laborers  or  the  fingers  of  dressmakers.  Here,  as  with  the  signs 
relating  to  age,  corroborative  value  is  often  all  that  can  be  attributed  to 
the  evidence  obtainable. 

Clerks  and  others  constantly  occupied  in  writing  frequently  have  a 
slight  callosity  on  the  tip  or  ulnar  border  of  the  little  finger,  with  a 
similar  thickening  of  the  epidermis  where  the  pen  is  grasped  between 
the  index-  and  middle  fingers  ;  occasionally  they  suffer  from  writer's 
cramp. 

Jewelers  may  show  slight  retraction  of  the  last  phalanx  of  the  left 
thumb.  They  do  not  suffer  with  special  frequency  from  cataract,  as 
was  once  claimed,  but  they  may  be  subject  to  cramps  or  to  spasms  of 
the  muscles  similar  to  those  of  writer's  cramp. 

Dressmakers  show  a  characteristic  sign  on  the  left  index-finger, 
where  the  skin  is  roughened  by  the  multiple  punctures  of  the  needle. 

Shoemakers  suffer  frequent  cuts  from  the  tliread  in  the  skin  of  the 
index-finger  between  the  second  and  third  phalanges.  The  nail  of  the 
left  thumb  is  usually  thick  and  hard,  and  its  edge  is  frequently  serrated 
or  broken  by  the  awl.  Constant  stooping,  especially  if  the  trade  has 
been  followed  from  early  life,  may  produce  a  moderate  lordosis  with 
slight  concavity  of  the  sternum.  The  pressure  of  the  last  may  cause  an 
indentation  of  the  lower  end  of  the  sternum.  The  skin  of  the  exterior 
surfaces  of  the  thighs  is  rough,  and  the  hair  is  usually  worn  away  by 
friction  of  the  apron.  These  latter  characteristics  are  not  at  all  peculiar 
to  shoemakers  alone. 

Workers  in  iron,  copper,  and  other  metals  usually  have  various 
callosities  on  the  hands  as  a  result  of  continued  friction  with  pieces  of 
these  metals.  Scra])ings  from  the  nails  and  fingers,  after  incineration 
and  solution  in  acids,  may  be  found  to  contain  traces  of  the  metals 
employed. 

Painters,  in  not  a  few  instances,  present  a  blue  line  along  the  bases 
of  the  teeth  or  along  Steno's  duct;  they  may  suffer  from  anemia,  con- 
stipation, and  colic;  and  less  frequently  there  may  be  a  persistent 
"  wrist-drop."  Lead  may  be  recovered  from  scra})ings  beneatli  the 
nails. 

Washerwomen  and   general  domestics  sometimes  may  be  recog- 


TlIK    IIAIK.  77 

nized  by  their  swollen,  soft  fingers  and  hands,  which  are  usually  of 
bright-red  color.  ''  Housemaid's  knee  "  and  "  flat  foot  "  are  common 
conditions  among  these  pe()i)l('. 

Tanners  usually  have  broad  callous  fingers  with  a  deep  brownish 
discoloration,  due  to  the  action  of  tannic  acid,  the  presence  of  which 
may  be  demonstrated  by  the  black  stain  ])roduced  by  tannate  of  iron, 
formed  by  treatment  of  the  skin  with  potassium  ferrocyanid. 

Sailors  are  usually  excessively  tanned,  while  their  hands  and  feet, 
being  frequently  soaked  in  water,  may  show  the  results  of  maceration 
in  the  form  of  inflamed  cracks  and  fissures. 

Laborers'  hands  present  a  miiformly  thickened  skin  with  various 
callosities  from  contact  with  the  tools  employed.  Tiie  muscles  of  the 
arms  and  shoulders  are  highly  developed,  and  the  arms  are  frequently 
carried  in  a  position  of  partial  flexion. 

Bakers  who  knead  the  dough  with  their  hands  often  have  callosities 
on  the  terminal  knuckles  of  the  fingers. 

Moingeard  ^  has  observed  a  siderosis  of  the  skin  of  the  left  little 
and  ring-fingers  in  millstone  grinders,  due  to  small  s])linters  of  steel 
that  are  driven  into  the  skin,  producing  marks  resembling  a  tattoo  and 
persisting  fi)r  years. 

The  Hair. — The  examination  of  the  hair  has  at  all  times  proved 
to  be  one  of  the  most  important  subjects  of  medicolegal  inquiry  in  con- 
nection with  the  identity  of  both  the  living  and  the  dead.  Hairs  are 
very  resistant  to  the  ordinary  processes  of  decomposition,  and  therefore 
may  remain  as  permanent  evidence  of  identity  long  after  other  features 
of  the  dead  or  mutilated  l)ody  have  become  unrecognizable.  Portions 
of  the  hair  are  specially  likely  to  become  detached  from  the  head  and 
transferred  from  one  person  to  another  in  any  violent  encounter.  In 
homicides  the  violence  is  most  frequently  applied  on  the  skull,  and  hairs 
readily  become  attached  and  often  fastened  by  blood  to  the  instrument 
used.  Vegetable  fibers  from  the  clothing  or  the  hairs  of  domestic 
animals  are  frequently  found  on  the  person  of  the  victim  or  assailant, 
and  their  presence  has  in  many  cases  furnished  very  cogent  evidence. 
Further,  the  most  complete  transformation  in  appearance  is  readily  pro- 
duced by  changes  in  the  color,  length,  and  arrangement  of  the  hair,  and 
consequently  these  are  the  most  frequent  means  of  disguise  employed  by 
criminals. 

A  chief  reason  why  the  hair  so  often  furnishes  decisive  evidence  lies 
in  the  positive  information  as  to  its  origin  and  character  obtained  by 
microscopic  examination.  When  hairs  are  recovered  from  a  dead  body 
or  from  its  vicinity,  they  should  be  carefully  inspected  and  any  adiie- 
rent  particles  preserved  ;  they  should  then  be  washed  in  water,  dried, 
and  mounted  in  balsam  or  glycerin  for  examination. 

The  hair   is  an  appendage  of  the  skin  corresponding  anatomically 

with   the   epidermis.      It   consists   of   a   shaft,  a  root,  and  a  bulbous 

extremity  imbedded  in  the  hair-follicles.     Microscopically  the  hair-shaft 

■consists  of  an  outer  cuticular  fibrous  portion  and  an   inner  medullary 

1  Annates  de  Hygiene  Puhlique,  xxiv.,  p.  39. 


78 


IDENTITY. 


darker  portion.  The  shaft  is  crossed  by  transverse  lines,  due  to  the 
layer  of  flat  cuticular  cells  that  cover  its  surface.  These  imbricated 
scales  are  more  prominent  at  the  root  of  the  hair,  where  they  produce 
a  distinctly  serrated  edge  along  the  shaft  when  it  is  seen  in  profile. 
The  fibrous  portion  of  the  shaft  is  composed  of  a  very  compact  mass 
of  fine  fibrils.  The  medulla  consists  of  spheroid  cells  containing  air- 
bubbles,  which,  by  transmitted  light,  appear  as  dark  granules.  The 
medullary  portion  is  absent  from  the  very  fine  hairs  of  the  general  body 

surface,  from  the  colored  hairs  of  the  scalp, 
and  from  the  hair  of  young  children. 

The  root,  with  its  bulbous  extremity,  is 
imbedded  in  the  hair-foUiele,  where  the 
substance  of  the  hair  is  intimately  con- 
nected with  the  epithelial  and  fibrous  ele- 
ments of  the  follicle,  from  which  it  is  de- 
veloped. The  color  of  the  hair  is  due 
principally  to  pigment  granules,  ])artly 
also  to  diffuse  pigment  found  in  the  cor- 
tex, and  to  the  presence  of  air-bubbles 
in  the  medulla,  which  alter  the  eflect  of 
the  pigment.  The  natural  color  of  the 
hair  is  evenly  distributed  and  extends 
down   into  the  hair-follicle. 

In  the  manner  of  growth  the  hair  of 
the  scalp  may  be  very  fine  or  coarse,  char- 
acters retained  throughout  life  ;  and  it  may 
be  straight,  wavy,  orcurly,  characters  which 
frequently  change  at  different  periods  of 
life.  The  distribution  of  the  hairs  of  the 
scalp  may  be  very  characteristic  :  some- 
times they  are  grouped  in  twos  or  threes ; 
sometimes  they  appear  singly  and  uni- 
ff)rmly  over  the  scalp.  Microscopic  ex- 
amination of  the  scalp  shows  that  this 
grouping  has  an  anatomic  basis  in  the 
connective- tissue  capsule  surrounding  two 
or  more  hair-follicles,  and  that  it  is,  there- 
fore, a  permanent  characteristic.  Blond 
hair  is  said  to  be  usually  more  abundant  and  stiffer  than  dark  hair,  a 
character  which  is  most  pronounced  Mith  the  beard,  while  the  diameter 
of  the  dark  hair  is  usually  larger.  The  hair-follicles  of  the  negro  scalp 
may  be  distinctly  curved,  and  may  even  point  away  from  the  surface  of 
the  scalp  (StewartV 

The  rate  of  growth  of  the  hair  of  the  scalp  is  about  one-half  inch 
a  month,  being  more  vigorous  in  youth  and  less  active  in  adult  life. 
It  has  repeatedly  been  observed  that  the  hair  mav  grow  after  death. 
In  the  New  York  Medical  Record,  August  18,  1877,  Dr.  Caldwell 
reported  that  in  1862  he  was  present  at  the  exhumation  of  a  body  that 


Fig.  12.— Hair-follicle  from  human 
BCalp :  a.  Hair ;  f*,  inner  root-sheath  ; 
c,  outer  root-sheath ;  d,  glassy  mem- 
brane ;  e,  fibrous  sheath  ;/,  hair-bulb  ; 
h,  hair-papilla. 


Tin:  HAIR.  79 

had  been  buried  for  four  years.  The  coffin  had  hecome  loosened  at  the 
joints,  and  the  haii-  of  the  corpse  appeared  at  these  openings.  There 
Avas  reliable  evidence  that  the  liead  had  been  shaved  l)efore  burial,  yet 
the  liair  of  the  head  measured  eighteen  inches  in  h'Ugth,  the  beard  eight 
inches,  and  the  hair  of  the  chest  four  to  six  inches.  The  nails  have 
also  been  found  to  increase  in  lengtli  after  death. 

When  portions  of  bajr  are  submitted  for  examination,  it  is  neces- 
sary to  determine  whether  the  hair  is  from  the  human  Iwdy,  from  one 
of  the  lower  animals,  or  if  it  be  hair  at  all  or  merely  vegetal)le  fiber. 

Human  hair  may  usually  be  ])()sitively  distinguished  from  that  of 
the  lower  animals  in  having  more  delicate  and  numerous  cross  stria- 
tions.  The  size  of  the  hair,  the  relative  width  of  medulla  and  cortex, 
and  the  location  and  color  of  the  pigment  should  also  be  considered  and 
compared  with  the  specimens  taken  from  different  parts  of  the  bodv, 
and,  if  the  hair  prove  to  be  other  than  human,  with  that  of  diflerent 
animals. 

The  long  hairs  of  animals  are  usuallv  found  mixed  with  a  finer, 
downy,  and  much  more  abundant  hair,  wliicli  is  not  seen  in  the  human 
body. 

The  region  of  the  body  from  which  the  hair  has  been  removed  can 
be  determined  wnth  considerable  accuracy  from  the  length,  si;^e,  color, 
stiffness,  curliness,  and  general  gross  appearance.  The  medulla  is  usu- 
ally absent  from  downy  hairs  and  may  be  wanting  at  some  points  in  the 
hairs  of  the  scalp.  The  coarsest  luiraan  hairs  are  those  from  the  beard, 
eyebrow,  axilla,  and  pubes,  and  are  from  ^^  to  yi^  of  an  inch  in 
diameter.  Hairs  from  the  nostrils,  back  of  hands,  scal]i,  and  the  e}e- 
lashes  vary  from  -^^  to  t^4-q-  of  an  inch  in  diameter.  The  line  downy 
hairs  are  very  much  smaller,  being  from  -^-jy^^^j  to  yJj)-^  of  an  inch  in 
diameter  (Tidy).  In  women  and  children  the  hair  is  usually  finer  than 
in  men.  The  short  hair  from  the  nostril  and  eyelid  is  circular  on 
section  and  unif)rmly  curved.  The  hair  that  appears  at  puberty  is 
usually  triangular  on  section,  as  of  the  beard  ;  or  oval,  as  of  the  pubes, 
but  seldom  quite  circular. 

When  it  is  determined  that  the  specimen  is  not  hair,  but  vegetable 
fiber,  it  is  important  at  times  to  asc(M*taiu  its  exact  nature.  It  is  some- 
times possible,  in  this  way,  to  identify  cotton,  linen,  and  other  garments. 

Cotton  fibers  are  characteristic  flattened  bands,  witli  thickened, 
refractive  borders,  and  twisted  into  irregular  sjrirals.  The  distinctly 
structureless  appearance  of  this  and  other  vegetable  fibers  greatly  aids 
in  separating  them  from  material  of  animal  origin. 

Linen  fibers  are  more  solid  and  rounded  than  cotton.  At  short 
intervals  these  fibers  present  irregular  transverse  joints,  and  when  the 
fiber  is  broken,  as  usually  occurs  at  these  joints,  the  ends  are  ragged 
and  fibrillated.  Linen  fibers,  when  treated  with  nitric  acid,  develop  an 
ol)lique  striation,  thus  differing  from  hemp,  of  which  the  fibers  are 
coarser  and  fail   to  show  striation  under  the  action  of  nitric  acid. 

Silk  and  wool,  although  of  animal  origin,  arc  usually  examined  as 
shreds  of  garments,  and  are,  therefore,  considered   in  this  connection. 


^0  IDENTITY. 

Silk  fibers  are  very  highly  refractive  solid  fibers,  free  from  transverse 
markings  and  evidences  of  cellular  structure.  Being  of  a  hornv 
nature,  they  turn  red  by  treatment  with  Millon's  reagent  (acid  solution 
of  mercuric  and  mercurous  nitrates),  in  a\  hich  reaction  they  diifer  from 
cotton  and  linen,  Avhich  remain  unchanged  after  this  treatment.  Wool 
consists  of  coarse,  irregular,  flexible,  very  curling  fibers,  shoeing  dis- 
tinctly the  cortical  cells,  and  marked  by  irregular  coarse  transverse 
striations.  Hairs  from  fur  garments,  such  as  seal,  otter,  sable,  and 
mink  skin,  should  be  compared  directly  with  genuine  samples  of  these 
furs. 

Manner  of  Extraction. — It  is  sometimes  important  to  know  whether 
the  hair  has  fallen  out,  been  torn  out,  or  been  cut  oif.  When  hair  falls 
out  naturally,  its  root  will  be  found  almost  as  dry  as  the  shaft,  and  well 
rounded  and  smooth.  When  torn  out,  the  old  hairs  may  closely 
resemble  the  fallen  ones,  but  of  those  that  were  firndy  fastened,  the 
roots  will  be  soft,  open,  and  moist.  Attached  to  the  root  will  be  a 
cellular  or  fatty  layer  which  belongs  to  the  follicle  or  the  sheath,  and 
which  has  been  torn  out  along  with  the  shaft.  A  single  hair  with 
rounded  atrophic  root  may  have  been  pulled  out,  but  if  a  considerable 
number  of  hairs  can  be  secured  for  examination  and  it  be  found  that 
they  all  have  rounded  atrophic  roots,  it  is  safe  to  conclude  that  they 
have  all  fallen  out. 

Hair  that  has  been  cut  ofF  by  scissors  shows  an  even  cut  edge,  but 
when  sawn  off*  by  successive  cuts  of  a  knife,  the  ends  are  more  or  less 
split.  In  either  case  they  lack  the  root.  The  long  hairs  from  the 
female  scalp  usually  show  a  s])litting  of  the  ends,  due  to  combing. 

Changes  in  the  Color  of  the  Hair. — Natural  changes  in  the  color 
of  the  hair  may  occur  very  frequently.  The  hair  of  children  usually 
grows  darker  with  increasing  age.  After  the  loss  of  hair  resulting 
from  infectious  diseases,  such  as  typhoid  fever,  the  retiu-ning  growth 
may  be  much  darker.  Sudden  fright  and  other  extreme  mental 
emotions  have  repeatedly  been  followed  by  sudden  and  pronounced 
bleaching  of  the  hair.  This  phenomenon  has  never  been  satisfactorily 
explained,  but  it  has  been  supposed  to  result  from  the  development 
of  air  between  the  elongated  cells  composing  the  shaft  (Schiifer). 
Premature  a^ravness  may  occur  without  known  cause,  and  it  has  often 
been  ascribed  to  heredity.  Metschnikoff  has  recently  referred  the 
natural  bleacliing  of  hair  to  the  action  of  bacteria.  Remarkable  differ- 
ences in  the  color  of  the  hair  of  parents  and  children  are  frequently 
observed,  as  in  the  children  of  albinos. 

Artificial  changes  in  the  color  of  the  hair  may  occur  accidentally. 
The  hair  of  ebony  turners  and  workers  in  indigo  may  develop  a 
greenish  tint,  and  that  of  copper  smelters  may  become  bluish  green 
(Tidy).  In  the  large  majority  of  cases  alterations  in  the  color  of  the 
hair  are  the  result  of  intentional  use  of  dyes. 

Dyeing  of  Hair. — Artificial  coloring-matter  of  many  varieties  may 
be  applied  to  the  hair  by  means  of  pomades.  Lamp-black  is  usually 
.selected   for  application   in   this  way.     Its  detection   is  easily  accom- 


THE    TEETH.  81 

pHshod  bv  dcmonstratiiii;  a  similar  discoloration  of  the  scalp,  and  by 
washincr  the  liair  in  ether,  by  which  the  crrease  is  dissolved  and  its 
admixture  of  carbon  particles  made  to  float  in  suspension   in   the  ether. 

To  darken  the  hair  solutions  of  metallic  salts  are  employed,  usually 
of  lead,  silver,  or  bismuth.  The  natural  sulphur  of  the  hair  produces 
the  sulphid  of  these  metals,  givinii;  various  dark  shades,  even  to  a  jet 
black.  Red  hair  contains  a  relatively  large  amount  of  sulphur,  and 
readily  changes  to  a  deep  black.  Or  the  sul])hur  may  be  supplied  by 
previously  washing  the  hair  in  a  solution  of  an  alkaline  sulphid,  preferably 
potassium  sulphid.  The  presence  of  a  metallic  dye  may  be  detected  by 
washing  the  hair  in  water  weakly  acidulated,  and  treating  the  water 
with  the  ordinary  chemical  tests  for  these  metals. 

To  bleach  the  hair  the  fatty  particles  should  first  be  removed  by 
washing  in  an  alkaline  solution,  after  which  repeated  applications  of 
strong  chlorin  water  will  cause  a  distinct  whitening  within  a  few  hours. 
Treatment  with  chlorin  renders  the  hair  very  brittle,  and  the  odor  of 
chlorin  is  very  tenacious.  A  golden  color  is  usually  produced  by  the 
application  of  peroxid  of  hydrogen,  which  oxidizes  the  natural  pigment 
of  the  hair,  giving  a  golden-yellow  color. 

To  demonstrate  the  fact  that  the  color  of  the  hair  has  been  artificially 
changed  it  is  necessary  to  determine  :  (1)  A  want  of  uniformity  in  the 
color.  (2)  A  growth  of  normal  hair  of  a  different  color,  to  l)e  seen  at 
that  portion  just  emerging  from  the  scalp.  (3)  Marked  differences  in 
the  color  of  the  scalp  and  that  of  the  other  portions  of  the  body  where 
the  dye  has  not  been  used.  (4)  The  presence  of  the  dye  in  the  shaft 
of  the  hair  in  a  difuse  form  and  the  absence  of  similarly  colored 
granular  pigment.  (5)  The  presence  of  secondary  alterations  in  the 
hair,  such  as  the  brittleness  resulting  from  chlorin.  (6)  The  presence 
of  a  metallic  salt  or  other  dye  in  the  washings  or  ashes  of  the  hair. 

The  nails  frequently  show  traces  of  the  trade  followed  by  the 
individual,  as  previously  detailed.  An  interesting  study  of  the  changes 
in  the  nails  due  to  disease,  occupation,  etc.,  may  be  found  in  Esbach's 
monograph.* 

The  Teeth. — Peculiarities  in  the  number,  formation,  and  condi- 
tion of  the  teeth  are  among  the  most  reliable  aids  in  identification  both 
of  the  living  and  of  the  dead.  Their  condition  is  of  specially  valuable 
assistance  in  the  determination  of  age.  The  successive  a])pearnnee  of 
the  teeth  of  the  first  and  second  dentitions  is,  in  the  great  majority  of 
children,  a  very  uniform  process,  although  in  different  individuals  it 
may  vary  widely.  At  birth  the  jaw  contains  the  dental  sacs,  with  the 
temporary  teeth,  of  which  the  crowns  are  already  calcified,  with  the 
calcified  crown  of  one  permanent  tooth,  the  first  molar. 

During  the  first  months  of  infancy  the  sacs  enlarge  and  produce 
rounded  swellings  in  the  gums  ;  fangs  grow  on  the  teeth,  and  soon  the 
sharp,  calcified  edge  of  the  tooth  is  thrust  through  the  gum.  The  first 
dentition  is  usually  completed  in  three  years. 

The  usual  periods  of  eruption  of  the  temporary  teeth  are  as  follows  : 
1  Modifications  de  la  I'halayigette,  etc.,  Paris,  187G. 
Vol.  I.— 6 


82 


IDENTITY. 


Six  to  eight  months,  lower  central  incisors.     Interval  of  three  to 
six  weeks.      Eight  months,  upper  central  incisors  ;  eight  to  ten  months,. 


Fig.  13.— Part  of  the  lower  jaw  of  a  child  three  or  four  years  old,  showing  the  relations  of 
the  temporary  and  permanent  teeth.  The  specimen  contains  all  the  milk-teeth  of  the  right  side, 
together  with  the  incisors  of  the  left ;  the  inner  plate  of  the  jaw  has  been  removed,  so  as  to  expose 
the  sacs  of  all  the  permanent  teeth  of  the  right  side,  except  the  eighth  or  wisdom-tooth,  wltiich 
is  not  yet  formed.  The  large  sac  near  the  ramus  of  the  jaw  is  that  of  the  first  permanent  molar, 
and  above  and  behind  it  is  the  commencing  rudiment  of  the  second  molar  (Quain's  Anaiomy). 

upper  lateral  incisors.     Interval  of  one  to  three  months.      Ten  to  twelve 
months,  lower  lat^al  incisors  ;  twelve  to  fourteen  months,  front  molars. 


Fig.  14.— Diagram  from  Welcker,  showing  on  the  left  side  the  order,  and  on  the  right  side  the 
time  (in  years),  of  appearance  of  the  permanent  teeth  of  the  upper  jaw  (Rauber). 

Interval  of  two  to  three  months.     Eighteen  to  twenty  months,  canines  ; 
twenty-two  to  twenty-four  months,  posterior  molars. 


THE   SKIN.  83 

Some  childivii  are  horii  with  the  incisors  already  cut,  wliile  others 
have  no  teeth  until  they  are  two  years  of  age.  A  curious  case  of 
entire  faihu-e  of  dentition  is  reported  in  the  Bodon  Medical  Journdl, 
March  6,  1879  :  The  man  was  twenty-four  years  of  age,  hut  had  never 
had  any  teeth.  Instances  of  a  third  dentition  in  advanced  life  are  also 
reported.  Rachitis  not  only  delays  the  develoj)inent  of  the  teeth,  but 
also  usually  interferes  with  their  pi'oju'r  formation.  Congenital  syphilis 
tends  to  hasten  the  eruption  of  the  temporary  teeth,  Avhile  the  permanent 
upper  central  incisors  are  frequently  notched  (Hutchinson). 

The  permanent  teeth  do  not  appear  with  such  regularity  as  the  tem- 
porary set,  and  furnish  somewhat  less  reliable  indications  of  age. 
The  periods  of  eruption  of  permanent  teeth  are  : 

Sixth  Year. — Four  anterior  molars. 

Seventh  Year. — Two  middle  incisors. 

Eif/hfh  Year. — Two  lateral  incisors. 

Ninth  Year. — First  bicuspids. 

Tenth  Year. — Second  bicusj)ids. 

Eleventh  to  Twelfth  Year. — Canines. 

Twelfth  to  Fourteenth  Year. — Second  molars. 

After  Tirenti/-first  Year. — Wisdom  teeth. 
The  records  which  dentists  sometimes  keep  of  the  condition  of  their 
patients'  teeth  may  be  found  valuable  for  purposes  of  identification.      A 
full  discussion  of  the  medicolegal  relations  of  the  teeth  is  contributed  by 
Manczka.^ 

The  Skin. — The  character  and  markings  of  the  skin  are  of  interest 
to  the  medical  jurist  principally  in  relation  to  scars  and  tattoo-marks, 
which  may  acquire  extreme  importance  in  cases  of  doubtful  identity. 
In  the  Tichborne  case  Sir  Roger  had  had  a  chronic  ulcer  on  one  arm 
which  must  have  left  a  scar ;  he  had  been  bled  repeatedly  from  both 
arms,  ankles,  and  one  temple,  and  he  had  been  tattooed  with  India  iidv. 
The  claimant,  however,  showed  no  traces  of  any  of  these  operations,  and 
himself  presented  a  large  brown  mark  on  the  side,  a  distinct  scar, 
probably  the  efl'aced  letters,  A.  O.,  tattooed  upon  his  arm,  none  of 
which  was  known  to  have  existed  on  the  person  of  Roger  Tichborne. 

The  possible  medicolegal  bearings  of  cicatrices  require  the  considera- 
tion of  the  following  questions  : 

1.  Does  a  wound  necessarily  leave  a  cicatrix? 

2.  May  a  scar  having  once  existed  be  obliterated  by  time  or  by 
artificial  means  ? 

3.  Can  the  age  of  a  cicatrix  be  inferred  from  its  apjiearance  ? 

4.  Can  the  character  of  the  wound  be  determined  from  the  appear- 
ance of  the  scar  ? 

5.  Can  the  size  of  a  wound  be  determined  from  the  scar? 
1 .   Does  a  wound  necessarily  leave  a  cicatrix  ? 

It  is  commonly  stated  that  all  wounds  involving  loss  of  substance 
necessarily  leave   scars.     But  this  very  general  rule  is   an  inadequate 
answer  to  the  question  in  hand,  for  some  wounds  involving  loss  of  sub- 
^  Oesterreich-Ungarische  VlerteljuhreNfichrift  fur  Zahnheilkiinde^  viii.,  H.  3. 


84  IDENTITY. 

stance  do  not  leave  scars,  while  others  without  loss  of  substance  produce 
permanent  cicatrices. 

The  solution  of  this  question  requires  the  application  of  the  ordinary 
laws  of  the  repair  of  tissue  after  a  division  of  continuity  or  loss  of  sub- 
stance. When  there  is  a  loss  of  substance  in  an  epithelial  tissue,  either 
skin  or  nuicous  membrane,  which  does  not  pass  below  the  level  of  the 
epithelium,  repair  is  effected  by  simple  proliferation  of  epithelial  cells, 
and  no  cicatrix  is  formed.  When  the  lesion  involves  other  deeper 
tissues,  subcutaneous  connective  tissue,  fat,  etc.,  the  process  of  repair 
follows  one  of  three  plans  :  (1)  There  may  be  immediate  adhesion  of 
the  divided  surfaces,  the  healing  proceeding  by  primary  intention.  Here 
the  exudation  of  fibrin  is  very  slight  and  merely  aids  in  the  cohesion  of 
the  surfaces,  while  the  formation  of  granulation  tissue  is  so  inconsider- 
able that  it  may  be  regarded  as  practically  absent.  (2)  There  may  be 
an  exudation  of  fibrin,  serum,  and  leukocytes  on  the  cut  surfaces, 
delaying  the  adhesion  of  these  surfaces  which  later  unite  by  secondary 
intention,  W\i\\  the  production  of  granulation  tissue.  (3)  There  may  be 
an  excessive  exudation  of  serum,  fil)rin,  and  leukocytes  ;  the  surfaces 
suppurate,  they  do  not  adhere  at  all,  and  the  wound  fills  uji  from  the 
bottom  with  granulation  tissue. 

Upon  the  amount  of  granulation  tissue  formed  will  depend  the  extent 
and  2^ermanence  of  the  scar,  for  this  tissue  is  never  entirely  replaced,  but 
becomes  converted  into  dense  cicatricial  connective  tissue.  Any  or  all  of 
the  foregoing  processes  may  occur  in  difi'erent  parts  of  the  same  wound, 
but  any  wound,  the  healing  of  which  has  not  occurred  entirely  through 
"  primary  intention,"  l)ut  has  been  attended  with  suppuration  or  infec- 
tion, will,  in  every  case,  leave  an  appreciable  scar. 

As  to  the  exact  process  that  takes  place  in  the  union  by  jirimary 
intention,  no  uniform  rule  can  be  stated.  The  subject  is  of  sufticient 
importance  to  warrant  the  following  quotation  from  Thoma.^  "  Macart- 
ney, Thiersch,  and  others  have  asserted,  in  regard  to  the  healing  of 
linear  incisions,  that  in  many  cases  the  surfaces  may  unite  so  closely 
that  the  line  of  the  woimd  is  indistinguishable  after  a  few  days,  and  can 
at  best  be  recognized  only  by  alterations  in  the  position  of  the  parts. 
Direct  union  of  the  separated  parts  without  the  formation  of  cicatricial 
tissue  is  supposed  to  be  possible  ;  but  this  view  has  as  yet  received  no 
conclusive  demonstration.  A  new  formation  of  tissue  seems  really  to 
be  necessary  for  firm  union  of  the  margins  of  a  wound,  although  it  may 
be  very  slight  in  amount.  Histologic  examination  of  the  incision  made 
in  laparotomies  shows  that  this  new  formation  of  tissue  greatly  depends 
on  the  general  condition  of  the  patient.  As  can  readily  be  understood, 
it  is  only  when  death  occurs  by  hemorrhage,  sepsis,  pyemia,  or  other 
pathologic  condition  that  the  laparotomy  wounds  can  be  examined  his- 
tologically within  a  few  days  of  o]>eration.  In  such  cases  the  surfaces 
of  the  wound  are  closely  apposed,  and  its  line  is  hardly  visible.  Fine 
strands  of  lym])hoid  cells  accompanying  the  vessels  are  all  that  is  to  be 
seen.  It  is  only  in  parts  where  the  margins  of  the  wound  are  slightly 
1   General  Pathology,  American  edition,  1896,  p.  484. 


THE    SKIN.  85 

apart  that  some  red  and  white  eorpuf^eles,  iiljriii,  and  yonn*:;  eonnective- 
tissue  cells  are  found.  In  addition  to  tliis,  the  margins  of  the  wound 
show  more  marked  infiltration  with  small  cells.  If,  in  such  cases,  the 
line  of  the  wound  is  not  visible  throughout  its  length  two  or  three  days 
after  operation,  this  is  chietiy  due  to  the  close  a[)position  of  the  ])arts 
jiroduced  hv  the  sutures,  but  does  not  necessarily  indieate  any  direct 
union.  The  more  closely  the  margins  of  the  wound  are  api)osed,  how- 
ever, the  more  delicate  will  be  the  sear  when  healing  is  completed,  and 
sometimes  it  really  does  subsequently  become  very  dillieult  to  see.  Any 
loss  of  tissue  which  is  converted  into  a  linear  wound  by  close  apposi- 
tion of  living  tissues  covered  with  epitheliiun  externally  heals  in  a 
similar  manner."  It  must  be  granted,  therefore,  from  these  considera- 
tions, that  it  is  possible  in  rare  cases  for  an  incised  wound,  even  thow/h 
associated  with  loss  of  substance,  to  leave  no  demonstrable  jjermanent 
cicatrix. 

2.  A  scar  having  once  existed,  may  it  be  obliterated  by  time  or 
by  artificial  means  ? 

In  order  to  reconcile  the  contradictory  observations  on  this  point  it 
is  again  necessary  to  consider  the  character  of  the  ])rocess  by  wlii(;h  the 
wound  has  healed.  Caspar  has  observed  the  marks  of  the  scariiicator 
to  disappear  in  two  or  three  years.  Devergie  thinks  such  marks  do  not 
disappear,  but  may  in  time  become  less  distinct.  There  can  be  no 
doubt  that  the  marks  of  the  scarificator  made  in  youth  are  commonly 
seen  in  old  age,  a  fact  which  is  emphasizetl  by  Tidy.  These  observa- 
tions, all  of  which  may  be  correct,  are  to  be  explained  only  by  the 
differences  in  the  rapidity  and  completeness  of  the  original  healing 
process,-  and  by  the  amount  of  cicatricial  tissue  then  produced.  Clean 
linear  incised  wounds  of  which  the  edges  are  properly  apposed,  and  in 
which  the  healing  jn-ocess  occurs  without  suppuration  or  excessive  ex- 
udation, leave  thin  delicate  scars  that  may  gradually  disappear.  On  the 
other  hand,  there  is  no  reliable  evidence  that  a  cicatrix  formed  after  con- 
siderable granulation  or  suppuration  has  ever  spontaneously  disajipeared. 

The  statement  of  Ogston  '  that  he  has  seen  "  all  traces  of  several 
chancres "  on  the  same  individual  disappear  in  six  weeks  has  been 
doubted  by  some  authors,  but  will  excite  no  great  surprise  among 
venereal  surgeons  who  have  had  much  experience  with  tlie  treatment 
of  superficial  chancroids. 

The  prominence  of  delicate  scars  left  after  jii'iniarv  union  may 
be  considerably  diminished  bv  prolonged  treatment  with  massage. 
Deforming  scars  are  often  excised,  but  the  resulting  loss  of  tissue  is 
almost  invariably  sufficient  to  produce  an  indelible,  although  less 
]>rominent,  cicatrix.  The  distinctness  of  cicatrices  may  be  t(Mii]iorarily 
increased  by  friction  of  surrounding  parts,  which  causes  hyperemia 
in  the  normal  tissue,  Avhile  the  limited  vascular  supply  of  cicatricial 
tissue  presents  a  corresponding  increase  in   its  blood   content. 

3.  Can  the  age  of  a  cicatrix  be  inferred  from  its  appearance  ? 
With  very  rapid  healing  of  inciscnl  wounds  it  is  stated  by  Thoma 

*  Medical  JiirispTudence,  p.  00. 


86  IDENTITY. 

that  the  incision  may  be  invisible  at  the  end  of  three  days,  although 
firm  union  has  not  }'et  occurred.  The  appearance  of  a  cicatrix  formed 
after  granulation  depends  upon  the  changes  occurring  in  granulation 
tissue  during  its  transformation  mto  cicatricial  tissue.  At  the  end  of 
from  seventy  to  ninety  hours  (Thoma)  there  are  dilatation  of  the  capil- 
laries and  increased  redness  about  the  edges  of  a  wound  healing  by 
secondary  intention.  This  soon  leads  to  the  formation  of  many  new 
capillaries  and  the  organization  of  the  exudate.  In  ordinary  incised 
wounds  the  process  of  healing  is  usually  complete  in  two  weeks,  leav- 
ing a  soft,  hyperemic,  red  cicatrix.  The  })rocess  is  more  rapid  in 
children  than  in  old  persons,  in  healthy  subjects  than  in  those  enfeebled 
by  disease,  hemorrhage,  or  sepsis.  Wounds  of  the  lower  extremities, 
where  venous  circulation  is  less  active,  sometimes  heal  more  slowly 
than  wounds  of  the  upper  extremities.  Healing  by  granulation  always 
requires  more  time  than  that  by  adhesion.  When  there  has  been  exten- 
sive loss  of  substance,  as  in  lacerated  and  contused  wounds  ;  when  the 
edges  are  imperfectly  approximated  or  are  drawn  apart  by  underlying 
muscles,  by  movements  of  joints,  or  by  the  restlessness  of  the  jiatient ; 
and  especially  when  tliere  have  been  infection  and  suppuration  in  a 
Avound — union  proceeds  more  or  less  by  granulation,  and  the  formation 
of  a  cicatrix  requires  much  longer  time. 

After  the  cicatrix  has  completely  organized  the  blood-vessels  gradu- 
allv  shrink,  the  effused  blood  is  disintegrated  and  removed  by  the  lym- 
phatics, the  new  connective  tissue  contracts,  and  there  remains  finally 
a  segment  of  dense  fibrous  tissue  with  i'ew  cells  and  few  blood-vessels, 
plainly  marked  oif  from  the  surrounding  skin  as  a  permanent  cicatrix. 
It  will  readily  be  seen  that  the  external  appearaiices  of  a  cicatrix  will 
vary  much  at  different  periods  of  its  organization.  Afresh  scar  is  soft, 
tender,  may  often  be  broken  down  by  firm  pressure,  and  is  reddish 
brown  in  color,  due  to  the  pressure  of  dilated  capillaries.  At  a 
variable  period,  usually  not  before  a  month  or  six  weeks,  the  blood- 
vessels and  connective  tissue  begin  to  contract,  the  cicatrix  becomes 
firm  and  takes  on  a  brownish  color.  After  months  or  years  it  may 
have  nearly  disappeared,  and  tlie  connective  tissue  is  contracted,  leaving 
a  white,  glistening,  hard,  insensitive  scar. 

4.  Can  the  nature  of  a  wound  be  determined  from  the  charac= 
ter  of  the  scar  ? 

Much  may  be  inferred,  and  some  positive  conclusions  may  be  drawn 
as  to  the  mode  of  origin  of  a  wound,  by  an  examination  of  scars,  as 
many  cicatrices  are  quite  characteristic. 

Accidental  icounds  produced  hy  crush  inr/  force  and  attended  with 
laceration  and  destruction  of  tissue  give  large  irregular  depressed 
scars,  and  there  may  also  be  signs  of  old  fractures  of  underlying 
bones. 

Bullet  ivounds,  when  produced  by  a  weapon  held  within  a  few  inches 
of  the  body,  produce  scars  that  are  larger  than  the  bullet,  irregular  in 
shape,  and  usually  surrounded  by  indelible  ])owder-stains.  When  a 
bullet  wound  has  been  produced  from  a  distance,  the  scar  is  depressed, 


THE    SKIN.  87 

discoidal,  and  smaller  than  the  bullet.  In  cither  case  the  scar  at  the 
point  of  exit  of  the  bullet,  from  llesh  as  from  bone,  is  larger  than  the 
scar  at  entrance. 

Stab  icounds  leave  triangular  scars,  smaller  than  the  blade,  and  less 
depressed  than  the  scars  from  bullet  wounds. 

Burns,  when  of  sufficient  intensity  to  cause  death  of  tissue  below 
the  epidermis,  are  followed  by  irregular.  Hat,  smooth  cicatrices,  corre- 
sponding in  size  to  the  original  lesion.  The  extent  of  these  cicatrices 
is  frequently  considerable,  and  the  contraction  of  the  new  connective 
tissue  mav  cause  marked  deformities.  The  cicatrices  of  burns,  rather 
more  frequently  than  those  of  other  wounds,  may  undergo  a  progressive 
hvpertrophy,  with  the  production  of  a  thick,  firm  mass  of  connective  tis- 
sue, with  atrophic  blood-vessels  and  dilated  lymphatics,  known  as  keloid. 

Surgieal  irounds  usually  result  in  clear  linear  cicatrices,  but  supjnn-a- 
tion,  extensive  removal  of  tissue,  and  })rolonged  use  of  drainage-tubes 
may  alter  their  appearance.  The  marks  of  tvet  cups  frequently  per- 
sist throughout  life  as  one  or  two  rows  of  six  small  triangular  white 
scars.  Venesection  is  usually  performed  on  the  median  cephalic  vein 
and  leaves  a  linear  cicatrix  lying  obliquely  across  the  course  of  the 
vessel  above  the  elbow.  Vaccination  scars  may  be  found  on  the  upper 
arm  or  calf  of  the  leg  as  flat  circular  cicatrices,  often  showing  depressions 
on  the  surface. 

Sears  from  Diseases  of  the  Skin. — Tuberculosis  of  lymph-nodes  or 
bones  frequently  produces  sinuses  leading  from  the  affected  tissue  to 
the  surface.  When  these  lesions  heal  spontaneously,  the  sinuses  are 
replaced  by  contracting  connective  tissue,  wdiich  leaves  an  irregular 
superficial  scar,  usually  much  depressed  and  comparatively  immovable 
wath  the  skin.  Secondary  syphilis  of  the  skin  may  produce  characteristic 
and  permanent  superficial  white  scars  on  the  back  of  the  neck,  as  well 
as  many  less  characteristic  brown  plaques  in  other  regions,  especially  on 
the  shins.  The  cutaneous  lesion  (jf  tertiary  syphilis,  arising  from  the 
gumma  which  destroys  considerable  tissue,  leaves  a  large,  irregular,  fre- 
quently pigmented,  depressed  cicatrix.  Smcdl-pox  pustules  are  followed 
by  small,  distinctly  depressed  cicatrices,  the  size,  location,  and  general 
appearance  of  which  are  usually  characteristic.  Transverse  superficial 
cicatrices  of  the  lower  abdominal  wall  are  rarely  missed  after  jn'cgnancy, 
but  may  be  seen  also  in  very  fat  men. 

5.  Can  the  size  of  the  original  wound  be  determined  from  the 
scar? 

The  principle  already  stated  with  regard  to  tlie  contraction  of  cica- 
tricial tissue  permits  the  general  rule  to  he  given  tiiat  a  scar  is  always 
smaller  than  the  original  wound.  This  contraction  will  be  greatest  in 
the  long  diameter  of  the  areas  of  new  connective  tissue,  whether  these 
areas  are  superficial,  as  after  burns,  or  extend  irregularly  among  mus- 
cles and  viscera,  as  after  the  healing  of  deep  sinuses.  The  contraction 
will  also  increase,  up  to  a  certain  limit,  with  the  age  of  the  cicatrix. 
Exceptions  to  these  rules  are  seen  in  the  case  of  some  ^vounds  inflicted 
in  childhood.      Vaccination  scars,  linear  operation   wounds,  nevi  and 


88  IDENTITY, 

the  scars  resulting  from  their  removal,  have  all  been  observed  in  children 
to  increase  in  size  with  the  natural  growth  of  the  body. 

Finally,  in  judging  of  the  value  of  the  evidence  furnished  by  scars, 
it  is  essential  to  recognize  the  fact,  frequently  ignored,  that  one  or  more 
scars,  identical  in  appearance  and  location,  are  often  to  be  found  on 
different  individuals,  and  that  the  presence  of  these  marks  can  seldom  be 
considered  a  positive  proof  of  identity. 

Tattoo=marks. — Some  famous  instances  are  recorded  in  the  older 
annals  in  which  the  presence  of  a  tattoo  served  as  a  means  of  identifica- 
tion. The  medicolegal  importance  of  these  markings  has  certainly  not 
decreased  at  the  present  time,  but  is  perhaps  greater  than  ever,  for  this 
curious  and  rather  inexplicable  custom  remains  a  very  common  one 
among  many  classes  of  society.  Sailors,  soldiers,  and  miners  furnish  a 
large  proportion  of  the  cases  commonly  seen  in  America.  Criminals, 
with  the  exception  of  the  more  intelligent  class  of  swindlers  and  forgers, 
frequently  indulge  the  taste.  Lombroso  devotes  considerable  attention 
to  the  subject  of  tattooing,  and  it  has  come  to  be  recognized  as  a  nearly 
constant  feature  of  criminal  anthropology.  Lombroso  *  and  Marandon 
de  Monty  el  ^  found  that  of  600  insane  persons,  13  per  cent,  were 
tattooed,  the  frequency  with  which  the  marks  were  found  being  in  inverse 
ratio  to  the  grade  of  degeneracy.  No  case  was  seen  in  a  patient  with 
advanced  psychic  degeneration.  So  much  more  frequently  were  the 
aggressive  and  dangerous  limatics  tattooed  that  Lombroso  believes  the 
presence  of  these  marks  might  be  made  of  diagnostic  value  between  the 
dangerous  and  the  comparatively  harmless  lunatics  and  criminals. 

Women  rarely  allow  themselves  to  be  tattooed,  except  prostitutes, 
who  frequently  cover  themselves  with  various  designs,  usually  obscene. 

The  process  of  tattooing  varies  considerably  with  the  operator,  but 
consists  essentially  in  making  multiple  needle  punctures  in  the  skin  and 
carrying  into  these  minute  wounds  particles  of  coloring-matter.  A^ery 
naturally,  from  the  necessary  lack  of  asepsis,  bacteria  are  often  carried  in 
with  the  coloring-matter,  which  is  itself  an  irritant,  and  considerable 
inflammation  usually  results  ;  the  neighboring  lymph-nodes  are  fre- 
quently inflamed  and  may  receive  a  permanent  deposit  of  pigment, 
demonstrable  after  death,  and  fatal  general  septicemia  has  occurred. 
From  Blockley  Hospital,  Philadelphia,  comes  the  report  of  the  inocula- 
tion of  nearly  a  score  of  persons  with  syphilis,  by  the  same  tattooer,  who 
moistened  tlie  needle  in  his  mouth  while  suffering  from  secondary  lesions 
of  the  buccal  mucous  membrane. 

The  coloring-matter  may  be  deposited  in  the  epidermis,  or  deep  in 
the  rete  mucosum,  or  in  the  subcutaneous  connective  tissue,  in  which 
latter  case  the  resulting  inflammation,  by  the  production  of  connec- 
tive tissue,  insures  the  permanence  of  the  stain.  Of  the  many  ])ig- 
ments  employed  in  the  process  the  red  colors  are  usually  vermilion 
(cinnabar),  and  the  blue  colors  are  indigo,  cobalt,  or  Prussian  blue, 
although  any  colored  ink  may  be  used.  The  ordinary  black  dye  con- 
sists of  carbon  particles  used  in  the  form  of  India  ink.     Nitrate  of 

^  L'uo7no  deliqueiite.  ^  Archives  d' Anthropologies  criminelies,  1892,  p.  373. 


THE    SKIN.  89 

silver  also  is  sometimes  employed.  Accidental  scars  resembling  tattoo- 
marks  are  frequently  produced  by  wounds  resulting  from  explosions,  as 
when  coal-dust,  gunpowder,  printer's  ink,  soot,  splinters  of  steel,  or 
other  insoluble  colored  jiartides  arc  carried  into  the  skin. 

The  perinanencc  of  taUoo-marks  depends  upon  the  elliciency  of  the 
operation  and  the  quality  of  the  dye  employed.  When  the  pigment  is 
deposited  merely  in  the  epidermis,  it  is  gradually  thntwn.  off  with  the 
outward  growth  and  exfoliation  of  the  layers  of  epithelial  cells.  When 
the  dye  is  passed  into  the  connective  tissue  of  the  derma,  the  resulting 
inilanunation  causes  an  encystment  of  the  particles,  and,  except  for  the 
few  grains  that  may  be  carried  off  by  the  vessels,  it  becomes  impossible 
to  remove  them  except  by  first  removing  the  epidermis  and  then  the 
connective  tissue  surrounding  the  dye.  Such  a  destruction  of  tissue 
may  readily  result  from  the  application  of  caustics,  but  m  every  case  a 
scar  must  remain. 

Considerable  difference  has  been  demonstrated  in  the  permanence  of 
the  different  dyes  employed.  Tidy  ^  found  that  in  121  cases  of  ver- 
milion tattoo  there  were  evidences  of  fading  in  16,  while  in  156  cases 
in  which  some  variety  of  carbonaceous  matter  had  been  used  he  was 
unable  in  a  single  instance  to  discover  any  indication  that  the  mark  had 
faded  since  the  operation.  In  this  author's  ex])erience  nitrate  of  silver 
has  also  proved  absolutely  indelible.  Vermilion,  indigo,  and  Prussian 
blue  are  generally  found  to  fade  perceptibly  in  time.  Common  inks 
are  more  permanent  and  insoluble,  while  carbonaceous  particles  are 
entirely  insoluble  and  most  permanent. 

Tattoo-marks  may  disappear  spontaneously,  as  demonstrated  by  the 
observations  of  Caspar,  Hutin,  and  Tardieu.  Caspar  ^  found  that  in 
4  of  37  cases  the  marks  had  entirely  disappeared.  Hutin  ^  rejjorts  that 
of  509  cases  examined  at  periods  between  thirty  and  sixty  years,  in  47 
there  was  not  a  trace  of  the  marks.  Tardieu  has  observed  the  total 
disappearance  of  2  vermilion  marks  in  thirty  years,  and  of  2  India-ink 
marks  in  forty-five  and  sixty  years  respectively,  out  of  76  cases  studied. 
In  many  others  of  the  preceding  cases  the  marks  had  perceptibly  faded. 

Tattoo-marks  mai/  be  removed  artiJiciaUi/.  The  extent  to  which  this 
removal  is  possible  depends,  as  stated,  principally  on  the  depth  to  which 
the  coloring-matter  has  been  carried.  Since  the  dyes  are  ]>ractically 
insoluble,  the  tissue  in  which  the  particles  are  imbedded  nnist  also  be 
removed  at  the  same  time.  Blisters,  escharotics,  and  the  knife  suggest 
themselves  as  the  most  natural  means  of  effecting  this  removal  of  tissue. 
According  to  Tardieu,  blisters  are  often  successfully  used  by  French 
criminals  to  remove  superficial  tattoo-marks.  He  describes  the  method 
by  which  a  criminal  entirely  removed  a  tattoo-mark  in  India  ink  in  six 
days.  The  skin  was  first  macerated  in  a  paste  of  lard  and  acetic  acid, 
then  thoroughly  rubbed  with  potash,  and  finally  with  dilute  hydro- 
chloric acid.  By  repeating  this  process,  successive  crusts  were  formed, 
until  the  level  of  the  dye  was  reached.      While  it  is  possible  that  the 

'  Legal  Medicine,  i.,  p.  191.  ^  Juirensic  Medici7ie,  i.,  p.  lOG. 

^  Recherehes  sur  les  tatonages. 


90  IDENTITY. 

accompanying  exudative  inflammation  might  have  extruded  some  of 
the  particles  from  the  rete  mucosum,  Tardieu's  claim  that  no  trace  of 
the  operation  remained  can  be  accepted  only  on  the  supposition  that  the 
dye  was  superficially  located.  Confluent  small-pox  has  been  known  to 
obliterate  tattoo-marks  in  children,'  and  it  seems  probable  that  sev^ere 
eczema  or  psoriasis  might  also  obscure  superficial  markings. 

Finger=prints. — It  has  been  thoroughly  demonstrated  that  the 
minute  anatomy  of  the  skin  of  the  finger-tips,  where  the  fine  lines  and 
ridges  of  the  epidermis  are  highly  developed,  is  of  very  permanent  struc- 
ture, and  has  for  years  been  sugo-ested  as  a  reliable  means  of  identifica- 
tion.  The  position  of  these  ridges  is  determined  by  the  presence  of  the 
papillre  of  fibro-elastic  tissue,  which  are  an  invariable  element  in  the 
structure  of  the  derma.  Over  the  general  body  surface  the  papilla?  and 
their  correspouding  ridges  are  very  low,  but  at  the  tips  of  the  fingers 
they  reach  a  height  of  0.25  mm.  (yito  i^^ch),  and  form  a  network  of  ele- 
vated lines  of  sufficient  height  to  produce  definite  impressions  when  the 
finger,  after  being  moistened  or  greased,  is  pressed  firmly  against  smooth 
paper  or  glass.    So  varied  and  characteristic  are  the  patterns  on  which  the 


%  ^ 


^> 


Thumb.  Index-  Middle  King  Little 

fluger.  linger.  linger.  finger. 

Fig.  15. — Finger-prints  from  one  hand,  showing  five  distinct  patterns. 

ridges  are  constructed,  and  so  unalterable,  as  it  appears,  do  these  patterns 
remain  throughout  life,  that  their  importance  as  a  means  of  identifica- 
tion has  been  generally  recognized,  and  extensive  treatises  have  been 
devoted  to  their  study .^ 

The  first  important  consideration  of  the  finger-prints  appeared  in  the 
Latin  thesis  of  Purkinje,^  who  described  nine  standard  patterns  upon 
which  the  ridges  are  arranged.  Isolated  references  to  the  subject  then 
appeared  from  time  to  time  without  attracting  special  attention.  In 
IS  SO  appeared  the  interesting  study  of  Fauld.^  At  the  same  time 
Tabor,  a  San  Francisco  photographer,  proposed  a  method  based  on 
finger-prints  for  the  registration  of  Chinese.  Meanwhile  Sir  AA'illiam 
Herschel  had  been  experimenting  with  finger-prints  as  a  means  of 
identifying  the  illiterate  Indian  coolies,  and  in   1877  he  adopted  their 

^  British  Medical  Jovrnnl^  1871,  ii.,  p.  532. 

■•^  See  Galton,  Vincjpr  Prints^  London,  1892. 

^  Breshiu,  1823,  piirtly  translated  by  Galton.  *  Nature,  xxii.,  p.  605. 


PINGER-I»KINTS.  91 

use  cxteiLsivelv  iu  the  govcninu'iit  offices  of  Bengal.'  From  1888  to 
1891  Galton,  of  London,  published  four  papers  on  finger-prints  and 
their  value  as  a  means  of  identitication,  and  in  LS92  his  complete 
treatise  appear(>d. 

Galton  divides  the  jwtterns  into  nine  classes,  which,  however,  are 
not  exhaustive.  These  divisions  are  based  upon  variations  in  the 
curved  lines  and  whorls  which  usually  occupy  the  center  of  the  thumb, 
and  of  transverse  and  obli(j[ue  lines  which  inclose  tliis  central  whorl. 
Their  minute  analysis  is  an  interesting  study,  but  not  essential  for  the 
ready  detection  of  likenesses  and  differences.  From  tiic  observations 
collected  by  Galton  it  appears  to  be  demonstrated  that  almost  absolute 
confidence  may  be  placed  in  the  permanency  of  these  designs,  a  con- 
clusion that  seems  justified  from  the  anatomic  basis  on  which  the  designs 
depend.  Of  700  cases  compared  at  different  periods,  but  a  single 
instance  was  noted  in  which  any  variation  was  disco\ered,  that  being 
the  union,  in  the  course  of  years,  of  a  ridge  that  had  been  cleft  in  early 
life.  The  radii  of  the  curved  ridges  necessarily  vary  with  the  state  of 
nutrition  of  the  individual  and  the  amount  of  adipose  tissue  in  the  ball 
of  the  finger.  Variations  in  the  separate  ridges,  also,  must  be  regarded 
as  a  possible  result  of  the  natural  growth  and  ex])ansion  of  the  member. 
Linear  or  transverse  division  of  ridges  is  produced  sometimes  by  the 
scars  of  minute  wounds  or  fissures,  and  they  are  most  irc(picntly  seen 
at  the  very  tips  of  the  thumbs.  But  that  any  fundamental  alteration 
in  the  direction  of  curves  or  in  tiie  origin  of  systems  should  occur, 
either  as  the  result  of  years  of  growth  or  of  disease,  seems  incompatilde 
with  the  histologic  structure  of  the  skin.  Galton  noticed  vcrv  marked 
similarity  in  the  finger-j)rints  of  members  of  the  same  family,  especially 
in  twins.     He  was  unable  to  discover  any  uniform  racial  characteristic. 

Very  accurate  impressions  may  be  obtained  by  rubbing  the  thumb 
in  lamp-black  and  pressing  it  firndy  against  a  sheet  of  well-glazed 
paper.  So  perfectly  are  impressions  received  under  suitable  circum- 
stances that  criminals  have  been  identified  by  means  of  these  imprints 
upon  paper  or  glass  articles  which  they  have  handled  with  moist,  greasy 
fingers.  In  collecting  evidence  from  the  scene  of  a  crime  it  is  impor- 
tant to  examine  papers,  clothes,  articles  of  glass,  and  the  polished  sur- 
face of  furniture  for  the  imjirints  of  fingers.  Gn  ]»aper,  the  impression 
may  be  developed  by  pouring  over  dilute  ink,  which  is  less  readily 
absorbed  along'  the  greasy  lines.  Forgeot  has  used  these  iiroductions 
for  photographing  the  impressions.  Glass  may  be  exposed  to  the  fumes 
of  hydrofluoric  acid,  as  recommended  by  Forgeot,  which  will  etch  out 
the  pattern  along  the  lines  not  protected  by  oily  mattei-.  AMien  polished 
surfaces  of  metal  or  wood  have  received  the  sliglitest  impress  of  the 
finger-tip,  the  imprint  may  be  developed  with  considerable  distinctness 
by  breathing  gently  upon  them,  when  the  moisture  of  the  breath  con- 
denses upon  the  lines  unprotected  by  the  oil  of  the  skin.  These 
impressions,  even  when  almost  invisible,  become  by  this  simple 
expedient  quite  distinct,  especially  upon  black  metallic  surfaces. 

1  Natwre,  xxiii.,  p.  23. 


92  IDENTITY. 

The  registration  of  finger-prints  is  now  a  feature  of  several  systems 
of  identification  and  seems  capable  of  much  wider  application  than  it 
has  yet  received. 

Galton's  conclusions  on  the  value  of  finger-prints  as  evidence  of 
identity  are  as  follows  :  "  On  the  average  no  great  reliance  can  be 
placed  on  a  general  resemblance  in  the  appearance  of  two  finger-prints 
as  a  ]:)roof  that  they  were  made  by  the  same  finger,  although  the  obvious 
disagreement  of  two  prints  is  conclusive  evidence  that  they  were  made 
by  different  fingers.  When  we  proceed  to  a  much  more  careful  com- 
parison and  collate  successively  the  numerous  minutise,  the  fact  remains 
tliat  a  complete  or  nearly  complete  accordance  between  two  prints  of  a 
single  finger,  and  vastly  more  so  between  the  prints  of  two  or  more 
fingers,  aftbrds  evidence,  requiring  no  corroboration,  that  the  persons 
from  whom  they  were  made  are  the  same.  Let  it  also  be  remembered 
that  this  evidence  is  applicable  not  only  to  adults,  but  can  establish  the 
identity  of  the  same  person  at  any  stage  of  his  life  between  bab}diood 
and  old  age,  and  for  some  time  after  his  death." 

Foot=prints. — The  human  foot  presents  such  a  variety  of  peculiar- 
ities in  size,  in  form,  as  determined  by  the  efficiency  of  ligaments,  in 
the  shape  of  different  bones,  and  in  the  character  of  the  skin,  that  evi- 
dence relating  to  these  members,  usually  foot-prints  in  soft  earth  or 
snow,  may  be  decisive  proof  of  identity. 

The  old  discussion  as  to  the  comparative  size  of  foot  and  foot-print 
was  maintained  by  Mascar  and  Causs6,  the  former  holding  that  the 
print  is  usually  smaller  than  the  foot ;  the  latter,  that  it  is  usually  larger 
than  the  foot.  The  experiments  of  Tidy  '  may  be  accepted  as  demon- 
strating that  the  relation  of  the  size  of  the  print  to  that  of  the  foot  is 
not  constant,  but  depends  upon  a  number  of  factors. 

1.  The  Material  upon  which  the  Print  is  3Iadc. — When  the  material 
is  composed  of  freely  movable  ])articles,  such  as  sand,  the  mark  is 
usually  smaller  than  the  foot.  In  moist  sand  a  print  may  quickly  be 
contracted  by  the  settling  of  the  soil.  In  clay  or  other  material  not 
composed  of  freely  movable  particles  the  print  is  always  larger  than  the 
foot.  "  This  appears  to  be  due  to  the  circumstance  that  in  walking  the 
foot  is  invariably  lifted  from  the  ground  in  the  opposite  direction  from 
that  in  which  it  was  placed  upon  it." 

2.  Tidy  believes  that  a  boot  of  which  the  edge  is  beveled  has  a  ten- 
dency to  make  the  print  smaller,  while  one  of  which  the  edges  slope 
outward  tends  to  make  a  print  larger  than  the  boot. 

3.  The  size  of  the  imprint  will  vary  with  the  rapidity  of  progression. 
Both  Ogston  and  Tidy  have  demonstrated  that  the  foot-print  of  a  person 
running  is  smaller  than  that  of  the  same  person  walking,  which  in  turn 
is  smaller  than  that  produced  when  standing.  In  going  up  hill  the 
imprint  of  the  ball  of  the  fi)ot  is  more  prominent,  while  in  descending, 
the  heel  will  be  the  more  prominent. 

Tliere  are  numerous  individual  peculiarities  in  foot-prints.  It  is  an 
almost  invariable  rule  that  men  can  be  recognized   at  a  distance  hy 

'  Legal  Medicine,  i.,  p.  176. 


HANDWRITING.  93 

peculiarities  of  gait  and  carriage.  jSlaiiy  of  these  peculiarities  consist 
in  sliding  and  twisting  movements  which  communicate  recognizal)le 
characters  to  the  foot-})rint.  A  good  illustration  of  this  fact  is  seen  in 
the  shuiHing  gait  of  sailors.  The  tracks  of  negroes  may  be  identified 
by  the  marked  tendency,  in  this  race,  to  walk  with  the  feet  pointing 
widely  ajiart. 

If  foot-prints  are  made  with  the  naked  foot,  by  careful  scrutiny 
much  additional  evidence  may  often  be  gained.  Scars  on  the  bottom  of 
the  foot  have  been  recognized  by  irregularity  in  the  outline  of  the  print. 
Wounds  of  definite  portions  of  the  foot  have  been  located  by  blood- 
stains found  at  corresponding  points  of  the  foot-print.  Similar  stains 
have  been  found  in  the  bottom  of  the  shoes  worn  after  injury.  Hyper- 
trophies or  bunions  of  the  inner  metatarsal  bones  may  leave  distinct 
traces.  The  characteristic  mark  of  the  flat-foot  is  bounded  l)y  nearly 
straio-ht  diverging  side  lines,  and  is  continuous  from  the  heel  to  the 
ball.  When  the  plantar  arch  is  high,  the  mark  of  the  ball  may  be 
entirely  separate  from  that  of  the  heel. 

It  is  sometimes  desirable  to  take  casts  of  foot-prints  to  be  offered  as 
evidence  in  court.  This  may  be  done,  as  suggested  by  Hougolin,  by 
heating  the  surface  with  a  pan  of  hot  coals  or  by  a  hot  iron,  and  scat- 
tering over  the  hot  surface  ])owdered  stearic  acid  or  paraffin.  When 
the  melted  paraffin  has  solidified,  plaster  casts  may  be  made  from  the 
model.  Molds  of  foot-prints  in  snow  'may  be  taken  in  thin  gelatin, 
cooled  until  about  ready  to  solidify,  and  a  plaster  cast  made  from  this 
model. 

Handwriting. — Xot  infrequently  it  becomes  necessary  to  compare 
specimens  of  handwriting  in  establishing  identity.    A  rather  famous  case 
is  that  of  Captain  Dreyfus,  who  was  convicted  of  treason  and  sentenced  to 
life  imprisonment  for  divulging  the  plans  of  defense  of  the  French  army. 
Perhaps  the  most  important  question  in  the  evidence  there  presented 
was  the  identity  of  certain  specimens  of  handwriting  in  the  letters  which 
conveyed  the  information  to  the  Prussians.      Very  marked  jieculiarities 
of  style  may  readily  suffice  for  identification,  but  when   two  specimens 
show  marked  differences,  either  accidental  or  intentional,  it  may  require 
close  study  to  prove  the  identity  of  the  writers.      It  may  be  said  of 
intentional  alterations  of  style   that  they  can    seldom   be   successfully 
maintained  for  any  length  of  time,  especially  if  the  subject  be  required 
to  write  rapidly.      In  such  cases  the  inclination  of  the  letters,  the  forma- 
tion of  capitals,  the  joining  or  separation  of  letters,  the  formation  of 
small  letters,  especially  r,  s,  e,  c,  and  f,  and  occasionally  the  orthog- 
ra])hy,  are  compared.      By   a   careful   simimary   of  the   evidence   thus 
obtained  a  correct  opinion  will   usually  l)e  reached.      It  is  im])ortant  to 
remember   in    this    connection    that   surprising   transformations    in    the 
character  of  the  handwriting  may  result  from  training  in  ]ienmanship. 
Young  persons  very  frequently  have  an  awkward  and   ill-formed  style 
until  some  occupation  arises   which  compels  them   to   write  long  and 
rajiidlv,  when  their  style  becomes  settled  and  charactc^ristic.      Diseases 
of  the  joints  of  the  hand,  such  as  rheumatism  or  rheumatoid  arthritis, 


94  IDENTITY. 

necessarily  alter  the  character  and  freedom  of  the  handwritmg.  Various 
nervous  diseases,  especially  those  attended  with  tremor,  produce  more  or 
less  irregularity  in  the  formation  of  letters.  The  haudwriting  of  the 
general  paretic  is  characteristic  and  may  he  one  of  the  earliest,  as  it  is 
one  of  the  very  sure,  diagnostic  signs  of  the  disease. 

During  the  past  few  years  the  identification  of  handwriting  has 
developed  into  a  complex  science  to  which  a  considerable  class  of 
experts  are  now  devoted.  The  exact  value  w^hich  the  courts  will 
place  upon  such  identification  has  not  yet  been  determined,  and  in  the 
Molineux  case  the  initial  verdict  was  set  aside  as  being  based  too  largely 
on  the  testimony  of  experts  in  handwriting. 

The  determination  of  mental  characteristics  by  means  of  the  hand- 
writing is  a  somewhat  fanciful  application  of  the  study  of  style  in  pen- 
manship, yet  in  the  hands  of  ex})erts  surprisingly  accurate  inferences 
are  often  made  regarding  age,  sex,  and  general  character. 

The  haudwriting  test  may  be  made  an  effectual  means  of  ascertaining 
whether  a  person  is  right-  or  left-handed,  a  question  that  has  arisen  in 
connection  with  doubtful  identity.  The  inference  whether  a  given 
specimen  has  been  written  by  the  right  or  left  hand  is  rarely  possible, 
although  the  writing  of  many  left-handed  jiersons  inclines  to  the  right. 

Photographs. — It  is  generally  claimed  that  the  value  of  photo- 
graphs as  a  means  of  identification  is  slight.  While  front  and  profile 
views  are  secured  in  the  Bertillon  system  of  identification  of  criminals, 
their  importance,  in  so  far  as  they  show  facial  expression,  is  regarded 
by  the  French  authorities  as  secondary.  Yet  in  many  cases,  by  showing 
positive  likeness,  they  may  furnish  valuable  corroborative  evidence  of 
identity.  As  negative  evidence  they  are  untrustworthy,  for  criminals 
frequently  transform  their  facial  expression  completely,  and  photogra- 
phers can  readilv  alter  negatives  so  as  to  change  the  character  of  the 
print  entirely.  Yet  in  the  case  of  the  Bryant  estate,  previously  cited, 
decisive  importance  was  attached  to  the  fact  that  one  of  the  claimants 
presented  an  old  photograph  that  resembled  those  found  in  the  trunk  of 
the  decedent.  The  opinion  of  the  court  in  this  case  runs  as  follows  : 
"  Where  claimants  to  an  estate  of  a  person  whose  identity  is  in  dispute 
introduce  in  evidence  a  photograph  of  their  kinsman  whose  identity  with 
the  deceased  they  are  attempting  to  establish  by  a  comparison  of  the 
])hotograph  offered,  and  two  photogra])hs  found  in  the  trunk  of  the 
deceased,  and  where  comparison  shows  a  marked  resemblance,  it  is 
strong  evidence  that  they  are  photographs  of  the  same  person  ;  espe- 
cially when  the  kinsman  of  claimants  had  the  same  name,  same  age, 
same  birthplace,  and  same  occupation  as  the  deceased." 

It  cannot  be  doubted  that  the  general  characteristics  of  the  face 
may  be  very  accurately  judged  from  front  and  profile  photograjilis, 
especially  with  regard  to  the  length  and  breadth  of  the  head,  the 
shape  of  the  nose,  and  the  characteristics  of  the  eyes,  eyebrows,  orbits, 
and  lips. 

General  Likeness. — The  evidential  value  of  similarity  in  appear- 
ance, especially  in   facial   expression,  has   often   been  demonstrated   in 


GENERAL    LIKHXESS.  IJo 

trials  turning  on  tlie  identity  of  individuals.  A  positive  resemblance 
in  appearance  lias  always  been  considered  as  strong  corroborative  evi- 
dence of  identity,  but  the  absence  of  such  resemblance  has  frequently 
l)een  shown  tit  be  valueless  as  proof  of  non-identity.  The  burglar, 
Charles  Peace,  who  was  executed  for  the  murder  of  William  Dyson 
(1(S79),  is  described  as  having  so  remarkable  a  power  of  changing  his 
features  and  altering  his  expression  that  he  was  accustomed  to  face 
detectives  who  not  onlv  knew  him  well  but  were  actuallv  seeking  to 
arrest  huu  at  the  thue  he  was  talking  to  them,  and  was,  moreover,  able 
to  deceive  his  wife  and  son  as  to  his  identity  (Tidy).  In  the  Tichborne 
case  the  great  dissimilarity  l^etween  Orton  and  Roger  Tichborne,  and 
the  evident  reseniljlance  of  Orton  to  the  father  of  Arthur  Orton,  carried 
much  weight  in  the  final  proof  of  the  real  identity  of  the  impostor. 
Xumerous  cases  of  illegitimacy  have  remained  undetermined  until  the 
child  grew  large  enough  to  show  unmistakable  resemblance  to  the  parent. 
Individuals  vary  greatly  m  their  power  of  recognizing  likeness  in  facial 
expression.  This  power  is  undoubtedly  capable  of  high  development, 
as  with  detectives  who  are  constantly  on  the  lookout  for  criminals  ;  and 
being  based  upon  one  of  the  most  tenacious  of  sensory  impressions,  that 
of  sight,  it  becomes  with  them  a  nearly  infallible  means  of  recognition. 

In  attempting  to  establish  the  presence  or  absence  of  general  like- 
ness it  is  important  to  reraemljcr  that  great  alterations  may  result  from 
years  of  hardship  or  even  from  temporary  exiiaustion,  and  that  disease 
or  dissipation  may  completely  transform  the  features  in  a  few  months. 
The  following  case  from  the  commentaries  of  Zacchias  has  been  fre- 
quently chosen  to  illustrate  this  point.  "  Cassali,  a  nobleman  of 
Bologna,  left  his  country  in  youth  and  was  supposed  to  have  jierished 
in  battle.  He  returned  after  an  absence  of  thirty  years  and  claimed 
the  property  appropriated  by  his  relatives.  He  was  so  changed  in 
appearance,  however,  that  none  of  his  friends  would  recognize  him,  and 
he  was  imprisoned  as  an  impostor.  Although  there  were  some  distin- 
guishing marks  upon  his  body,  the  judges  were  in  doubt  as  to  the 
identity,  and  consulted  Zacchias  to  kno\v  if  the  countenance  could  be 
so  changed  as  to  render  it  unrecognizable.  Zacchias  assigned  several 
causes  for  the  transformation,  such  as  age,  change  of  climate,  manner 
of  life,  and  disease,  all  of  which  he  claimed  might  produce  such  altera- 
tions, and  the  judges  decided  in  favor  of  Cassali." 

An  interesting  question  forming  the  pivotal  point  in  some  trials  has 
been  the  leuf/th  of  time  and  inten.vty  of  fight  iiec<:s.\-(ir;/  for  the  recof/nition 
of  faces.  The  following  case  will  serve  for  illustration  :  A  lady,  on  her 
passage  home  from  India,  was  awakened  one  dark  night  by  some  one 
moving  about  m  her  cabin.  A  sudden  flash  of  lightning  enabled  her 
to  see  a  man  bending  over  one  of  her  trunks,  and  his  features  ajipeared 
so  distinct  that  she  was  able  next  day  to  recognize  him.  The  stolen 
articles  were  found  upon  him  and  he  acknowledged  the  theft.' 

Tidv  believes  that  a  flash  of  liiihtning  is  in  manv  cases,  but  bv  no 
means  in  all,  sufficient  for  identification.  He  was  able,  on  one  occasion, 
'  Montsjomery,  Cycloped'ui  of  PracUcal  Medicine. 


96  IDENTITY. 

to  detect  a  pin  on  the  ground  by  a  flash  of  lightning  and  to  pick  it  up 
at  the  next  flash.  The  great  inequality  in  the  duration  of  lightning- 
flashes  is  a  matter  of  common  remark,  nor  can  any  one  doubt  that  faces 
may  be  distinctly  recognized  during  some  of  the  more  prolonged  flashes. 

Full  recognition  has  often  been  made  by  the  light  from  the  dis- 
charge of  firearms,  but  the  possibility  of  such  ideutification  was  not 
accepted  without  repeated  experiments  called  forth  by  the  following 
case,  taken  from  the  Causes  Celebres,  and  widely  quoted.  The  Sieur 
Labbe,  on  a  dark  night  in  May,  1808,  was  riding  with  the  widow 
Beaujean,  attended  by  a  servant  on  foot.  The  servant  was  wounded 
by  a  gun  fired  through  a  hedge  which  was  bordered  by  a  ditch.  Both 
swore  they  recognized  the  assassin  by  the  light  of  the  discharge.  The 
prisoner,  being  sentenced  to  death  on  this  evidence,  appealed  to  the 
Court  of  Cassation,  and  many  experiments  were  made  by  Guineau, 
Dupuis,  Caussin,  and  others,  which  seemed  to  disprove  the  possibility 
of  recognition  under  such  circumstances.  The  light  was  so  transient 
that  it  was  scarcely  possible  to  see  distinctly  the  form  of  the  head,  and 
that  of  the  face  could  not  be  recognized.  The  sentence  was  reversed, 
but  Fodere  afterward  contested  this  decision,  and  a  subsequent  case,  con- 
firmed by  the  experiments  of  Desgranges,  of  Lyons,  showed  the  possi- 
bility of  such  recognition. 

Tidy  refers  to  three  other  similar  cases  in  the  English  annals,  and 
concludes  from  the  reported  experiments,  including  his  own,  that : 
"Given  a  moderate  distance,  a  dark  night,  and  the  absence  of  any 
artificial  light,  and  that  the  smoke  produced  by  the  explosion  is  not 
great,  recognition  is  possible  in  the  majority  of  cases.  Given  the 
reverse  of  these  conditions,  a  considerable  distance,  a  weak  flash,  and 
much  smoke,  and  we  believe  the  chances  of  identification  would  l)e 
doubtful." 

Peculiarities  of  Special  Senses. — It  is  necessary  to  refer  only 
briefly  to  some  common  peculiarities  of  vision  and  hearing,  and  to  point 
out  that  they  have  occasionally  fiu'uished  important  evidence  in  relation 
to  identity.  The  examination  of  the  eyes  may  disclose  errors  of  refrac- 
tion or  motility,  and  it  may  transpire  that  the  existing  imperfections  of 
vision  would  prevent  the  witness  from  seeing  objects  claimed  to  have 
been  recognized.  Daltonism,  or  color-blindness,  either  partial  or  com- 
plete, is  a  very  common  aflfection,  and  its  existence  is  unsuspected. 
Before  corporations  had  begun  to  institute  careful  examination  of  the 
color  sense  in  their  employees  railroad  accidents  were  occasionally 
attributed  to  this  natural  defect  of  vision  in  sM'itchmen,  engineers,  and 
other  operators.  The  configuration  of  the  eyes  and  eyebro^vs  and  the 
color  of  the  iris  form  important  details  in  the  Bertillon  system  of 
registration  of  criminals. 

The  limits  of  hearing  have  at  times  been  discussed  in  connection 
with  questions  of  identity,  and  natural  or  acquired  defects  in  this  sense 
may  have  important  l>earings. 

Peculiarities  of  speech  are  so  common  and  varied  that  hai'dly  any 
one  fails  to  identify  well-known  friends  by  the   sound  of  the   voice. 


THE    SYSTEMATIC    REGISTRATION    OF    CRIMINALS.  97 

Lisps,  stuttering,  and  nasal  or  shrill  intonation  have  all  hccn  offered  as 
evidence  of"  identity  in  le<>al  ])ro('edures.  Staininei'inii;  is  usually  a  per- 
manent detect,  while  lis])in<;-  may  often  he  improved  hv  section  of  the 
median  raphe  that  hinds  down  the  ti])  of  the  tonji^ue,  Cardozo '  refers 
to  "the  logical  but  somewhat  startling-  rule,"  announced  by  a  decision 
in  New  York,  that  the  identity  of  a  dog  may  be  shown  by  the 
peculiarity  of  its  bark.  The  instances  in  current  legal  records  of 
identification   by  the   sound  of  the  voice  are  rather  luuiierous. 

THE  SYSTEMATIC  REGISTRATION  OF  CRIMINALS. 

While  in  the  majority  of  cases  requiring  proof  of  the  identity  of 
criminals  the  comparison  of  the  results  of  physical  examination  with 
the  less  definite  data  derived  from  the  statements  of  witnesses  is  neces- 
sary, the  increasing  use  of  systems  of  registration,  especially  that  of 
Bertillon,  must  tend  to  make  identification  of  criminals  a  process  of 
almost  mathematic  certainty. 

The  Bertillon  system  is  based  upon  four  chief  measurements  : 
(1)  Head  length;  (2)  head  breadth;  (3)  middle-finger  length;  (4) 
i'oot  length.  These  measurements  are  believed  to  remain  constant 
during  adult  life.  Each  of  these  dimensions  is  subdivided  into  3 
classes,  small,  medium,  large,  and  the  resulting  81  classes  are  filed  away 
as  primary  headings  for  reference.  Each  of  these  primary  headings  is 
again  subdivided,  according  to  other  measurements,  such  as  the  height, 
the  span,  the  cubit,  the  height  of  the  bust,  and  the  length  and  breadth 
of  the  ear.  The  nose  is  described  according  to  its  j^rofile.  The  bridge 
may  be  concave,  rectilinear,  or  convex.  The  direction  of  the  alse  nasi, 
with  reference  to  the  perpendicular  of  the  profile,  may  be  ascending, 
horizontal,  or  descending.  The  classification  of  ears  is  determined  by 
the  character  of  the  outer  border,  the  pr<^file  of  the  antitragus,  the 
contour  of  the  lobe,  and  the  adherence  of  the  lobe  to  the  cheek.  The 
color  of  the  eyes  is  made  the  basis  of  7  classes.  The  final  result  is 
that  a  total  of  12  headings  is  secured,  of  which  11  are  sulxlivided  into 
3  classes  each,  and  1  into  7  classes.  Thus  there  are  3'^  X  7,  or  more 
than  a  million  possible  combinations.  Of  course,  the  addition  of  one 
other  measurement,  subdivided  in  3  classes,  would  tri])le  the  total 
number  of  combinations,  and  Bertillon  claims  that  the  system  may 
readily  be  extended  indefinitely.  The  presence  of  peculiar  marks  upon 
the  body  is  also  detailed  ;  and  the  measurements  of  the  head,  nose,  and 
ears  are  supjilemented  by  front  and  profile  ])hotographs. 

The  ap])lication  of  the  Bertillon  system  was  begun  in  l.S,S3  and  very 
soon  proved  its  great  efficiency.  The  prisoners  sentenced  in  the  courts 
of  Paris  to  more  than  a  few  days'  imprisonment  are  sent  to  the  Bertillon 
depot  daily,  and  measurements  taken  and  catalogued.  These  files  are 
forwarded  to  Lyons  and  Marseilles,  where  similar  systems  are  in  openi- 
tion,  and  it  is  thus  rendered  possible  to  identify  in  a  few  minutes  an 
old  offender  who  has  previously  served  a  term  in  a  Enrich  prison,  Li 
1890,  562  prisoners  who  gave  false  names  were  identified  by  this  sys- 

^  Hamilton,  Legal  Medicine,  i.,  p.  225. 
Vol..  I.— 7 


98  IDENTITY. 

tern,  while  only  four  others,  who  escaped  recognition  by  this  method, 
were  by  other  means  discovered  to  have  been  previously  convicted. 

There  are,  however,  a  number  of  limitations  to  the  Bertillon  system. 
The  amount  of  labor  required  to  measure  a  large  number  of  convicts 
necessitates  the  employment  of  a  large  force  of  men,  and  inaccuracies 
creep  into  the  records.  The  system  is  applicable  only  to  the  adult,  in 
which  age  alone  the  measurements  are  known  to  be  constant,  for  in  the 
large  class  of  youthful  criminals  natural  growth  rapidly  alters  the 
length  of  limbs  and  occasionally  the  character  of  features.  The  effects 
of  disease,  accident,  and  change  in  nutrition  must  also  be  regarded. 

Such  considerations  led  Drs,  Greenleaf  and  Smart,  of  the  United 
States  Army,  to  discuss  the  anthropometric  system,  and  to  devise  a 
method  of  registration  in  which  the  presence  of  indelible  body-marks, 
scars,  tattooes,  birthmarks,  and  moles,  was  made  the  basis  of  .identifica- 
tion. Some  such  system  was  necessitated  by  the  fact  that  desertions 
from  the  United  States  Army  were  found  greatly  to  exceed  deserters, 
owing  to  repetition  of  the  offense  by  the  same  person.  Drs.  Greenleaf 
and  Smart  believed  that  if  all  the  body-marks  of  deserters  were  recorded 
and  the  marks  of  recruits  were  compared  with  the  records,  it  would  be 
possible  to  detect  repeaters.  A  reasonable  correspondence  in  height, 
age,  and  hair  Avas  thought  to  be  an  important  requisite  in  the  identifica- 
tion. This  method,  therefore,  makes  the  permanent  body-marks  ot 
chief  imjiortance,  which  were  only  secondarily  considered  in  the  Bertillon 
system,  while  exact  anthropometric  measurements  w^ere  discarded,  one 
inch  above  or  below  the  recorded  height  being  allowed  for  variation  or 
defective  measurement.  A  card  is  employed  for  each  man,  stamped 
Avith  outline  figures  of  the  anterior  and  posterior  body  surfaces,  and 
divided  by  dotted  lines  into  smaller  regions.  These  cards,  on  w^hicli  is 
indicated  the  location  of  all  permanent  l)ody-marks,  are  filed  at  the 
Surgeon-General's  office.  For  the  comparison  of  recruits  and  deserters 
a  registry  in  two  volumes  is  made,  one  for  light-eyed  and  one  for  dark- 
eyed  men.  Each  is  subdivided  into  groups  of  pages,  according  to  the 
height  of  persons  entered,  and  each  page  is  ruled  in  colunms  for  body 
regions.  Tattooed  and  non-tattooed  men  of  similar  height  and  eyes  are 
entered  on  opposite  pages.  On  the  register,  S.,  T.,  B.,  M.,  are  used  as 
abbreviations  for  scar,  tattoo,  birthmark,  and  mole. 

This  register  was  inaugurated  in  1891  and  has  proved  very  effectual. 
Such  a  method  avoids  the  confusion  likely  to  result  from  errors  or 
natural  variations  in  measurements,  is  applicable  to  all  ages,  and  is 
possibly  less  cumbersome,  but  lacks  the  accuracy  and  detail  of  the  Ber- 
tillon system. 

Galton,  who  discusses  both  these  systems  at  length,  pointing  out  their 
advantages  and  defects,  very  urgently  recommends  the  adoption  of 
finger-prints  in  addition  to  the  methods  of  identification  now  in  use. 
His  remarks  are  Avell  worth  consideration  : 

"  There  are  almost  always  moles  or  birthmarks  serving  for  identifi- 
cation on  the  body  of  every  one,  and  a  record  of  these  is,  as  noted,  an 
important  though  subsidiary  part  of  the  Bertillon  system.     Body-marks 


IDEXTIFICATION    OF    :\[rTILATED    REMAINS.  99 

are  noted  in  the  English  registers  of  criminals,  and  it  is  curious  how 
large  a  jH'oportion  of  these  men  are  tattooed  and  scarred.  How  far 
these  body-marks  admit  of  Ijeing  usefully  charted  on  the  American  plan 
it  is  difficult  to  say,  the  success  of  tlu^  method  being  largely  dependent 
on  the  care  with  whicli  they  are  recorded.  .Vs  observations  of  this  class 
reqnire  the  person  to  be  undressed,  tiiey  are  unsuitable  for  |)opular  pur- 
poses of  identification,  but  the  marks  have  the  merit  of  serving  to 
identify  at  all  ages,  which  the  measurements  of  the  lind>s  have  n(»t. 

.  "  It  seems  strange  that  no  register  of  this  kind,  so  far  as  I  know, 
takes  account  of  the  teeth.  If  a  man,  on  being  first  registered,  is  defi- 
cient in  certain  teeth,  they  are  sure  to  be  absent  when  he  is  examined 
on  a  future  occasion.  He  may  and  probably  will  in  the  meantime  have 
lost  others,  but  the  fact  of  his  being  without  specified  teeth  on  the  first 
occasion  excludes  the  possibility  of  his  being  afterward  mistaken  for  a 
man  who  still  possesses  them. 

'•  Xow  finger  patterns  have  l)cen  shown  to  be  so  indc[)endent  of 
other  conditions  that  they  cannot  be  notal)ly,  if  at  all,  correlated  with 
the  body  measurements  or  with  any  other  feature,  not  the  slightest  trace 
of  any  relation  between  them  having  yet  been  found.  For  instance,  it 
woukl  be  totally  impossible  to  fail  to  distinguish  between  the  finger- 
prints of  twins  who,  in  other  respects,  appeared  exactly  alike.  Finger- 
prints may,  therefore,  be  treated  without  the  fear  of  any  sensible  error, 
as  varying  quite  independently  of  the  measures  and  records  in  the  Ber- 
tillon  svstem.  Their  inclusion  would,  therefore,  increase  its  power  fully 
500  fold 

"  When  the  data  concerning  a  suspected  person  are  discovered  to 
bear  a  general  likeness  to  one  of  those  already  on  the  register,  and  a 
minute  comparison  shows  their  finger-prints  to  agree  in  all  or  nearly  all 
particulars,  the  evidence  thereby  afforded  that  they  were  made  by  the 
same  person  far  transcends  in  trustworthiness  any  other  evidence  that 
can  ordinarily  be  obtained,  and  vastly  exceeds  all  that  can  be  derived 
from  any  number  of  ordinary  anthropometric  data.  By  itself  it  is  amply 
sufficient  to  convict.  '  Bertillonage '  can  rarely  supply  more  than 
grounds  for  very  strong  suspicion  ;  the  method  of  finger-prints  affords 
certainty.  It  is  easy  to  understand,  however,  that  so  loug  as  the  pecu- 
liarities of  finger-prints  are  not  generally  understood,  a  juryman  would 
be  cautious  in  accepting  their  evidence,  l)ut  it  is  to  be  hoped  that  atten- 
tion will  now  become  drawn  to  their  marvelous  virtues,  and  that  after 
their  value  shall  have  been  established  in  a  few  conspicuous  cases  it  will 
come  to  be  popularly  recognized." 

These  considerations  are  very  reasonable  criticisms  of  the  system  of 
criminal  registration  now  in  use,  and  they  j)oint  ont,  it  would  seem,  the 
lines  upon  which  tiiese  systems  must  be  developed  and  perfected  if,  as 
is  extremely  desirable,  they  are  to  receive  universal  ado])tion. 

IDENTIFICATION  OF  MUTILATED  REMAINS. 

The  discussion  of  identity  has  thus  far  concerned  oidy  the  living 
person  or  the  entire  dead  body.     When  only  a  portion  of  the  body  or 


100  IDENTITY. 

a  few  bones  have  been  recovered,  the  problem  of  identification  becomes 
greatly  complicated  and  its  solution  often  impossible.  Much  depends 
upon  the  acuteness  of  those  persons  who  discover  such  fragments,  for 
the  situation  and  surroundings  of  the  remains  often  give  a  decisive  clue 
to  their  identity  and  one  that  it  is  entirely  impossible  to  obtain  from  an 
examination  of  the  remains  alone.  The  locality  in  which  the  portions 
of  the  body  are  found  should  be  thoroughly  searched  for  other  frag- 
ments, for  articles  of  clothing,  jewelry,  or  any  material  with  which  the 
remains  were  covered,  for  weapons  or  instruments  used  by  the  assailant, 
for  foot-prints,  finger-prints,  hair,  etc.;  in  fact,  every  peculiarity  of  the 
situation  should  be  carefully  noted,  numerous  instances  being  recorded 
that  show  the  extreme  importance  of  these  minutiae.  The  final  identi- 
fication of  Dr.  Parkman  was  effected  by  the  discovery  of  35  pieces  of 
bone  in  the  ashes  of  a  stove,  which  pro\'ed  the  absence  of  teeth  from  the 
lower  jaw.  Artificial  teeth  were  also  found  in  the  ashes  and  were 
identified  by  the  dentist  as  the  ones  he  had  recently  made  to  replace  the 
lost  teeth.  In  the  recent  discovery  of  the  murders  attributed  to  Her- 
manns, of  Salt  Lake  City,  the  teeth  and  jewelry  of  one  victim  were 
found  in  the  ashes  of  a  stove,  a  portion  of  the  corpse  under  a  stone 
floor,  while  the  blood-stained  overalls  of  the  murderer  were  hidden 
away  in  another  portion  of  the  l)uilding.  In  some  of  the  White- 
chapel  murders  the  remains  of  the  victims  A\ere  fomid  scattered  at 
widely  distant  points. 

When  such  portions  of  a  body  or  skeleton  are  recovered  it  becomes 
important  to  determine,  first,  whether  or  not  they  are  human  remains. 
The  presence  of  a  small  portion  of  skin  may  at  once  decide  the  question, 
and  the  careful  examination  of  an  entire  bone  will  usually  be  equally 
conclusive.  When,  however,  smaller  fragments  of  bone  or  flesh  are 
recovered  it  is  seldom  ])ossible,  by  either  gross  or  microscopic  examina- 
tion, to  determine  whether  the  fragments  are  of  human  (H-  animal  origin, 
unless  they  are  specially  characteristic.  The  remains  proving  human, 
the  question  whether  they  belong  to  the  same  body  may  be  determined 
by  comparison  of  the  skin,  the  cut  surfaces,  the  soft  parts,  and  the 
length  and  development  of  the  bones.  The  presence  of  wounds  capable 
of  producing  death  should  be  ascertained  and  their  nature  noted. 
Attempt  to  destroy  the  remains  by  burning  or  by  packing  in  chlorid  of 
lime  may  prevent  any  definite  conclusion  being  reached. 

Having  decided  that  all  the  recovered  fragments  belong  to  the  same 
human  body,  the  examination  is  continued  in  the  endeavor  to  determine 
the  sex,  age,  stature,  occupation,  manner  of  death,  and  probable  identity 
of  the  l3ody,  an  undertaking  that  may  involve  any  or  all  of  the  ques- 
tions relating  to  identity.  The  remarkal)le  success  that  not  infrequently 
attends  such  systematic  efforts,  even  under  apparently  hopeless  condi- 
tions, has  never  been  better  illustrated  than  in  the  case  of  Dr.  Parkman.' 

Dr.  Parkman,  of  Boston,  disappeared  on  November  23,  1849,  and 
suspicion  of  his  murder  was  aroused  against  Professor  Webster,  as  the 
missmg  man  was  last  seen  alive  entering  the  medical  college  where 

1  Comp.  vs.  Webster,  5  Cush.,  295. 


EXAMINATION    OF    THE    MIND.  101 

Webster  was  professor  of  cliemistrv,  for  the  j)urposc  of  reeeiving 
money  that  had  loiiu'  \)vvu  owed  liini.  A  seareh  in  the  cheniieal 
laboratory  resulted  in.  tlie  discovery  of  a  ju'lvis,  riuht  thioh,  and  left 
leir  Ivintj:  in  the  vault  of  a  privv,  M'hile  in  the  crinders  of  the  furnace 
were  foinid  fragments  of  cranial  bones,  of  vertel)nc,  artificial  teeth,  and 
a  gold  plate.  In  a  tea-box  covered  with  tar  and  minerals  were  found 
the  left  thigh  and  the  trunk,  in  the  left  side  of  which  was  found  a  deep 
stab  wound  to  which  the  death  of  the  victim  was  attributed.  All  these 
parts  when  put  together  fitted  accurately,  and  the  lines  of  incisions 
showed  that  they  had  been  tnade  by  some  one  who  had  an  accurate 
knowledge  of  anatomy  and  skill    in   the   use  of  the  knife. 

The  length  of  the  body,  as  caleulated  from  that  of  tlie  long  bones, 
j>roved  to  be  70.5  inches,  which  was  exactly  that  of  Dr.  Parkman. 
The  age,  as  shown  by  the  skin,  hair,  and  general  appearance,  was 
estimated  at  between  fifty  and  sixty  years,  while  the  sclerosis  of  the 
arteries  indicated  that  the  age  was  at  least  sixty  years,  which  was  the  age 
of  Dr.  Parkman.  The  teeth  and  the  gold  plate  were  identified  by  the 
dentist  as  those  of  a  peculiar  form  that  he  had  made  for  Dr.  Parkman, 
and  the  fragments  of  bone  reproduced  the  right  half  of  the  lower  jaw 
and  showed  the  absence  of  teeth,  which  the  dentist  proved  had  been 
lost  by  Dr.  Parkman.  The  identity  of  the  dead  man  was  thus  positively 
established.     Webster  was  fourid  if-uiltv  and  finally  confessed  the  crime. 

EXAMINATION  OF  THE  MIND. 

Having  concluded  the  consideration  of  the  objective  evidences  bear- 
ing on  identity  that  may  be  elicited  by  physical  examination  of  the 
living  or  dead  body,  it  remains  to  consider  the  importance  of  a  critical 
examination  of  the  mental  qualities  of  an  individual.  It  is  not 
intended  to  include  here  the  limitless  field  of  circumstantial  evidence, 
although  it  has  been  repeatedly  shown  that  such  may  be  the  clearest 
possible  proof  of  identity.  But  some  remarkable  trials  have  shown 
that  an  examination  of  the  mental  and  moral  capacities  of  an  individual, 
and  especially  of  the  memory,  may  produce  the  most  convincing  ])roof 
of  identity.  The  conclusions  drawn  from  facts  thus  elicited  are  all  the 
more  trustworthy  because  they  depend  upon  the  reason  and  not  upon  the 
senses,  and  because  the  influences  affecting  the  ordinary  laws  of  mind 
are  very  few  compared  with  the  limitless  number  of  j)ossible  exceptions 
to  physical  laws.  Thus  it  is  cpiite  possible,  although  not  jirobable,  that 
an  individual  should  fail  to  show  any  traces  of  a  score  of  cicatrices 
known  to  have  existed  in  youth,  but  it  is  impossible,  at  least  so  far  as  may 
be  judged  by  the  annals  of  neuropathology,  that  an  individual  otherwise 
in  soimd  health  should,  in  a  few  years,  entirely  forget  his  native  tongue. 
This  abstract  evidence  may  l)e  derived  from  the  examination  of  the 
mental  cajiacities,  and   ])rincipally  of  the  memory,  of  an   individual. 

Mental  Capacities. — The  decision  in  some  of  the  well-known 
cases  already  referred  to  was  potently  influenced  by  the  discovery  of 
wide  discrepancies  in  the  mental  capacity  of  two  individuals.     In  the 


102  IDENTITY. 

case  of  Martin  Guerre  the  claimant  was  shown  to  be  entirely  ignorant 
of  the  art  of  fencing,  in  which  Guerre  had  been  an  adept.  In  the  Tich- 
borne  case  it  was  shown  that  the  claimant  was  utterly  wanting  in  the 
rudiments  of  education,  in  which  Sir  Roger  had  been  thoroughly 
grounded.  It  appeared  also  that  the  claimant  did  not  exhibit  certain 
instincts  that  must  have  existed  in  a  man  of  high  birth  and  breeding. 
The  claimant  held  tenaciously  to  habits  and  tastes  that  were  inconsistent 
with  those  of  the  youthful  Tichborne.  Indeed,  the  whole  intellectual 
character  of  this  man  was  widely  at  variance  with  that  of  the  one  he 
pretended  to  be,  and  this  fact  bore  overwhelmingly  against  a  strong  line 
of  testimony  in  his  favor. 

Memory. — Even  more  decisive  was  the  evidence  derived  from  the 
examination  of  the  memory  of  the  claimants  in  the  above  cases.  The 
claimant,  Orton,  "  gave  evidence  of  a  tenacious  memory,  recalling  the 
name  of  a  dog  and  the  number  of  a  trooper's  horse,  but  he  failed  to 
remember  his  supposed  mother's  Christian  name,  his  place  of  birth,  the 
companions  of  his  youth,  the  college  where  he  was  educated,  his  Paris 
residences,  the  relatives  at  whose  house  he  was  always  a  welcome  guest, 
or  the  friends  who  helped  him.  Roger  took  leave  of  his  dying  grand- 
father at  Bath ;  Orton  does  not  admit  of  any  ignorance  of  the  event, 
but  lays  the  scene  at  Knoyle." ' 

No  more  cogent  proof  of  the  falsity,  of  their  claims  could  be  desired 
than  the  fact  that  neithei-  Orton  nor  Dutille  could  speak  the  mother- 
tongue  of  Tichborne  or  Guerre,  the  men  they  pretended  to  be.  Roger 
Tichborne's  native  language  was  French,  which  he  spoke  continuously  in 
France  and  frequently  in  England  for  twenty-five  years.  When  he 
finally  acquired  English  it  was  with  a  pronounced  French  accent.  The 
claimant,  however,  could  neither  read  nor  speak  French,  and  it  was 
rightly  deemed  imj)ossible  that  a  man  otherwise  in  sound  health  could 
have  entirely  forgotten  his  mother-tongue.  It  might,  however,  be 
asked  if,  with  the  more  advanced  knowledge  of  neurology,  some  of  the 
rarer  forms  of  aphasia  may  not  involve  a  complete  loss  of  the  mother- 
tongue.     A  case  re]>orted  by  Dr.  Peterson  is  here  of  interest : 

A.  E.,  male,  fifty-eight  years  of  age,  born  in  Alsace,  spoke  German 
and  French  until  his  eighteenth  year,  when  he  came  to  America,  where 
he  gradually  acquired  English,  At  the  beginning  of  his  illness  he  held 
a  position  as  head  waiter,  having  in  his  charge  twenty  waiters  with 
whom  he  had  to  speak  both  French  and  German.  About  two  years 
before  examination  he  began  to  lose  the  power  to  speak  French  and 
German,  and  in  one  month  he  comj>letely  lost  the  ability  to  speak 
these  languages,  while  retaining  his  command  of  English.  On  exam- 
ination, the  sight  and  hearing  were  found  to  be  normal.  There  was  no 
paresis  or  aj^raxia.  Of  English,  his  reading  and  com]irehension  were 
normal,  but  there  were  slight  motor  ai)hasia  and  very  slight  agraphia. 
French  he  could  read  well,  but  his  comprehension  of  phrases  was 
imperfect,  although  he  could  grasp  the  main  ideas.  There  were,  how- 
ever, complete  motor  aphasia  and  agraphia,  and  he  could  neither  speak 

'  Guy  and  Ferrier. 


EXAMINATION    OF    THE    MLND.  103 

nor  write  a  word  of  French.  Gorman  he  could  read  fairly  well,  but  its 
comprehension  was  difficult,  while  he  could  neither  s]>eak  nor  write  a 
word  of  German,  the  motor  a})hasia  and  agra})iiia  in  this  lan<:;uau-e  being 
complete,  as  with  French.  The  diaj^nosis  was  cerebral  softenin*^  from 
endarteritis.  The  patient  then  began  the  study  of  liis  native  tongues 
and  made  for  a  time  some  progress  in  their  recovery  ;  afterward  the 
softening  became  progressive  and  tinally  residted  in  complete  loss  of 
speech. 

The  judge  in  the  second  trial  of  Guerre's  case  held  it  possible  that 
the  claimant,  after  a  wandering  life  of  eight  years,  might  have  entirely 
forgotten  the  language  he  had  spoken  for  twenty  years.  It  is  hardly 
]n-obable  that  the  courts  of  the  present  day  would  admit  such  a  possi- 
bilitv,  for  althouti-li  facilitv  in  the  use  of  a  language  mav  rai)idlv  fail, 
the  form  of  speech  acquired  in  youth  produces  so  permanent  an  impres- 
sion on  the  memory  that  its  traces  must  always  be  recognizable. 

On  the  other  hand,  a  |)artial  or  even  striking  similarity  in  the  mental 
character  and  memory  should  not  be  accepted  as  final  proof  of  the 
identity  of  two  persons.  It  will  readily  be  seen  that  the  chief  and  con- 
vincing strength  of  the  claims  of  Orton  and  Dutille  lay  in  their 
familiarity  with  the  lives  of  Tichl)orne  and  Guerre.  Had  it  not  been 
that  they  possessed  a  knowledge  of  many  minute  particulars  (»f  the 
lives  of  these  men,  their  dissimilarity  in  other  matters  could  not  have 
been  overlooked.  But  in  both  of  these  cases  the  knowledge  was 
ac((uired  accidentally  and  for  the  intentional  purpose  of  deception. 
Dutille  had  long  been  an  intimate  friend  and  comrade  of  Guerre's,  had 
learned  from  him  the  history  of  his  life  and  his  family  secrets,  and  had 
received  from  him  some  family  relics  at  a  time  when  Guerre  thought 
himself  about  to  die.  The  opportunities  for  acquiring  such  personal 
knowledge,  especially  at  the  jiresent  day,  are  so  numerous  that  the 
possession  of  a  number  of  such  isolated  facts  should  serve  to  rouse 
susjiicion,  rather  than  confidence. 

It  must  be  admitted,  finally,  that  the  real  conflict  of  evidence  in  the 
above  cases  centered  in  the  examination  of  the  mind,  in  the  presence  of 
which  the  evidence  derived  from  the  physical  examination  was  largely 
obscured  or  variously  interpreted  according  to  the  weight  of  other 
testimony,  and  it  may  be  claimed  with  confidence  that  in  such  cases  a 
careful  and  thorough  investigation  of  the  mind  will,  with  very  rare 
exceptions,  lead  to  a  correct  and  decisive  conclusiou. 


THE  SIGNS  OF  DEATH. 


Death  may  be  defined  as  the  cessation  of  those  physical  and 
chemical  processes  on  which  the  phenomena  of  life  depend.  Animal 
life,  however,  is  a  very  complex  condition,  and  while  the  scientific  con- 
ception of  death  requires  the  complete  cessation  of  all  the  physico- 
chemical  or  molecular  processes  of  life,  practically  and  before  the  law, 
the  animal  body  may  be  dead  long  before  the  complete  cessation  of  all 
the  molecular  j)rocesses  of  life.  The  hair  and  nails,  for  example,  may 
grow  to  a  considerable  length  after  death. 

There  is  also  a  variance  between  the  legal  and  the  scientific  concep- 
tion of  a  living  person.  The  law,  as  held  in  England  and  in  some  States 
of  America,  recognizes  as  living  beings  only  those  born  in  a  condition 
capable  of  maintaining  an  independent  existence.  Science  recognizes 
the  fetus  as  a  living  being,  and  finds  it  almost  as  violent  a  procedure  to 
interrupt  the  current  of  maternal  blood  circulating  about  the  fetus  of 
three  months  as  to  cut  off  the  supply  of  air  from  an  adult  man. 

The  legal  scope  of  the  term  "  death,"  thus  considerably  contracted 
in  comparison  with  the  scientific,  involves  the  final  and  complete  cessa- 
tion of  those  vital  functions  upon  which  depends  the  life  of  an  individual 
capable  of  maintaining  independent  existence.  The  physical  processes 
here  concerned  are  chiefly  respiration  and  circulation,  on  the  activity  of 
which  life  principally  depends,  and  the  cessation  of  which  is,  usually, 
readily  determined.  The  fact,  however,  that  molecular  activity  may 
persist  some  time  after  respiration  and  circulation  have  ceased  renders  the 
proof  of  the  final  and  complete  cessation  of  these  vital  functions  often 
a  matter  of  difficulty,  and  necessitates  a  careful  consideration  of  all  the 
external  sig"ns  of  death. 

Hansemann  lias  pointed  out  the  close  and  almost  altruistic  inter- 
dependence of  the  molecular  processes  and  the  life  of  the  cells  of  the 
various  organs.^  The  truth  of  his  conception  is  well  illustrated  when 
death  occurs  through  the  sudden  interruption  of  a  vital  function  at  a 
time  when  cellular  activity  is  entirely  normal,  and,  under  favorable 
conditions,  is  capable  of  restoring  vital  functions  after  their  temporary 
cessation.  On  the  other  hand,  in  death  from  infections  diseases  molec- 
ular or  cellular  decay  keeps  pace  with  or  precedes  the  failure  of 
respiration  and  circulation,  and  these  functions  are  seldom  restored  after 


once  ceasmg. 


The  chief  importance  of  determining  the  reality  of  death  is  not,  at 
the  present  day,  the  danger  of  burying  the  living,  but  the  possibility 
^  Die  Specifitat,  den  Altruismus,  und  der  Anaplasie  der  Zellen,  Berlin,  1893. 
104 


CONDITIONS    SIMULATING    DEATH.  105 

that  efforts  at  resuscitation  may  not  be  properly  attempted  in  eases  of 
apparent  deatli.  There  are  undouhtedly  some  ^vell-authenticated  in- 
stances in  which  it  has  been  sup[)osed  by  fairly  competent  persons  that 
death  has  occurred  and  yet  the  body  has  been  resuscitatech  In  eases 
of  prolonged  syncope  and  ])artial  as|)"hyxia  by  drowning,  bodies  ap])ar- 
ently  dead  have  frequently  been  resuscitated  by  draughts  of  cold  air  or 
dashes  of  cold  water,  or  other  nervous  stinudus.  It  is  possible  also  tiiat 
the  hasty  burial  of  bodies  during  jilagues  or  on  the  battle-field  has  led 
to  the  interment  ot"  bodies  in  wliicii  lite  might  have  been  restored  by 
appropriate  measures.  But  the  idea  that,  with  the  present  methods  of 
disposing  of  the  dead,  in  civilized  countries,  it  is  ])ossible  that  a  lK)dy 
can  be  buried  alive  is  not  to  be  entertained.  Nevertheless,  in  some 
localities  and  classes  of  S(iciety,  and  with  a  very  few  intelligent  persons, 
the  possibility  of  such  a  catastro])he  constitutes  a  real  source  of"  fear. 

Conditions  Simulating  Death. — The  conditions  marked  by  a 
temporary  inhibition  of  the  respiration  and  circulation  liable  to  be  mis- 
taken for  death  are  syncope,  partial  asphifxia,  catalepsy,  and  trance. 

Syncope,  or  the  ordinary  fainting  attack,  is  usually  quickly  over- 
come, and  the  appearances  of  death, — failure  of  respiration  and  heart- 
sounds,  coma  and  pallor, — though  for  a  few  seconds  very  alarming,  are 
seldom  complete,  and  soon  are  replaced  by  a  return  of  the  signs  of  life. 
Yet  ordinary  syncope  is  always  a  dangerous  condition,  calling  for 
immediate  and  vigorous  treatment  to  prevent  the  heart  failure  from 
becoming  ])ermanent.  In  some  cases  of  syncope,  therefore,  the  only 
means  of  determining  whether  or  not  deatli  has  occurred  is  the  result  oi 
treatment. 

Partial  asphyxia,  by  drowning  or  by  other  means,  is  a  rather  fre- 
quent cause  of  apparent  death.  Attempts  at  resuscitation  have  been 
successful  when  begun  as  long  as  one  hour  after  submersion,  and  the 
result  in  such  apparently  hopeless  conditions  shows  the  impossibility  of 
at  once  determining  the  reality  of  death  under  such  circumstances.  It 
is  known  that  infants  asphyxiated  during  a  prolonged  second  stage  of 
labor,  or  by  pressure  upon  the  cord,  may  be  resuscitated  several  minutes 
after  the  pulse  and  respiration  have  ceased. 

Catalepsy. — This  phenomenon  in  its  most  pronounced  forms  is 
characterized  by  complete  loss  of  consciousness,  of  which  the  onset  is 
usually  sudden.  The  muscles  of  the  whole  or  a  part  of  the  body 
become  rigid,  but  the  limbs  may  usually  be  moved  and  ])laccd  in 
various  positions,  where  they  remain  for  some  time.  Superficial 
reflexes  are  abolished.  The  sensibility  to  touch  and  pain  may  be  lost. 
The  temperature  is  lowered.  The  respiration  and  heart's  action  are 
much  reduced.  ''  A  deficient  control  of  the  motor  centers  of  the 
cortex,  permitting  their  overaction,  regulated  by  different  impulses,  and 
repeated  in  the  spinal  cord,  is  the  best  theory  we  can  at  present  frame  of 
the  condition  "  (Gowers).  The  simulation  of  death  produced  by  catalepsy 
is  usually  not  marked,  and  the  diagnosis  presents  no  great  difficulty. 

In  trance  the  ap])earances  of  death  are  much  more  striking,  and  the 
condition  has  in  several  instances  ended  fatally.     Consciousness  may  be 


106  THE    SIGNS    OF    DEATH. 

entirely  abolished.  The  face  is  extremely  pale.  The  limbs  usually 
remain  flaccid,  but  may  become  rigid  or  show  spasmodic  movements. 
The  reflexes  may  be  lost,  and  the  pupils  may  be  dilated  and  immobile. 
Sensation,  although  frequently  retained  or  heightened,  may  be  abolislied. 
The  pulse  and  respiration  may  become  temporarily  imperceptible.  The 
combination  of  these  symptoms  persisting  for  some  hours  may  present 
a  very  close  resemblance  to  death.  In  the  diagnosis  Gowers  recom- 
mends attention  to  the  following  points  :  (1)  The  absence  of  signs  of 
decomposition ;  (2)  the  normal  ophthalmoscopic  appearance  of  the  fun- 
dus oculi ;  (3)  the  persistence  of  the  excitability  of  the  muscles  to  elec- 
ti'icity. 

Of  the  pathologic  basis  of  trance  nothing  is  known.  "  The 
phenomena,  viewed  in  the  light  of  the  induced  varieties,  suggest  a  state 
of  inhibition  or  at  least  an  inaction  of  the  nerve-cells  subserving  the 
higher  psychic  functions,  and  that  the  morbid  state  spreads  to  the 
lower  centers  in  varying  degree "  (Go^\■ers). 

A  partial  physiologic  counterpart  of  trance  is  to  be  seen  in  the 
hibernation  of  some  animals  :  wheii  the  heart-beats  fall  to  eight  to  ten 
a  minute,  the  respirations  are  still  lower,  and  the  temperature  is  sub- 
normal. It  is  said  that  some  Indian  Fakirs  have  the  power  of  holding 
their  breath  and  passmg  into  a  state  of  trance  in  which  the  heart-sounds 
become  inaudible.  Tidy  ^  has  collected  a  luunber  of  cases  in  which  the 
various  phenomena  of  cataleptic  trance  were  fully  or  partially  presented. 
A  well-authenticated  and  very  peculiar  case  of  voluntary  suspension  of 
the  heart's  action  and  respiration  is  the  well-known  story  of  Colonel  Town- 
send.  Chevne,"  in  describing  the  case,  says  :  "  He  told  us  he  had  sent 
for  us  to  give  him  an  explanation  of  an  odd  sensation  he  had  for  some 
time  observed  in  himself,  which  was,  that,  composing  himself,  he  could 
die  or  expire  wdien  he  pleased,  and  yet,  by  an  effort,  he  could  come  to  life 
again.  This  it  seems  he  had  sometimes  tried  before  he  had  sent  for  us. 
We  all  three  felt  his  pulse  first ;  it  was  distinct,  though  small  and  thready. 
He  composed  himself  on  his  back  and  lay  in  a  still  posture  some  time. 
While  I  held  his  right  hand  Dr.  Baynard  laid  his  hand  on  his  heart 
and  Mr.  Skrine  held  a  clear  looking-glass  to  his  mouth.  I  found  his 
pulse  sink  gradually,  till  at  last  I  could  not  feel  any  by  the  most  exact 
and  nice  touch.  Dr.  Baynard  could  not  feel  the  least  motion  in  his 
heart,  nor  Mr.  Skrine  discern  the  least  soil  of  breath  on  the  bright 
mirror  he  held  to  his  mouth.  Then  each  of  us  in  turn  examined  his 
arm,  heart,  and  breath,  but  could  not  by  the  nicest  scrutiny  discover  the 
least  sign  of  life  in  him.  This  continued  about  half  an  hour.  As  we 
were  going  a^yay,  thinking  him  dead,  we  observed  some  motion  al)out 
the  body,  and  upon  examination  found  his  pulse  and  the  motion  of  his 
heart  returning;  he  began  to  breathe  gently  and  speak  softly.  This 
experiment  was  made  in  the  morning  and  he  died  in  the  evening.  On 
opening  the  body,  nothing  was  discovered  but  disease  of  the  kidney, 
for  which  he  had  long  been  under  medical  treatment,  all  the  other 
viscera  being  perfectly  sound." 

'  Legal  Medicine,  i.,  p.  139.  ^  Treatise  on  Nervous  Diseases,  p.  307. 


SPECIAL    SIGNS    OF    DEATH.  107 


SPECIAL  SIGNS  OF  DEATH. 


It  need  hardly  be  said  that,  as  a  rule,  the  ordiiiarv  sig'iis  of  death 
are  too  well  kuowa  to  need  deseri[)ti()ii  and  too  striking-  to  admit  of 
doubt.  Under  some  conditions,  however,  the  cessation  of  the  breathing 
and  ])uLse  is  not  accompanied  by  any  changes  in  the  countenance  other 
than  those  of  sleep.  When  death  occurs  in  a  condition  of  venous  or 
arterial  hyperemia  the  stoppage  of  the  circulation  is  at  once  marked  by 
pronounct'd  changes  in  the  color  of  the  skui ;  but  with  gradual  heart 
failure,  especially  in  afebrile  states,  there  may  be  little  or  no  change  in 
the  countenance.  It  has  been  noted  also  that  some  hours  after  the  signs 
of  death  are  apparently  conclusive  the  rapid  onset  of  decomposition 
may  produce  a  Hushing  of  the  face  and  a  partial  return  of  life-like 
appearance.  Even  the  experienced  observer,  relying  usually  upon  the 
appearance  of  the  countenance  as  the  readiest  indication  of  death,  is 
sometimes  forced  to  make  a  careful  physical  examination  before  he  is 
able  to  convince  himself  as  to  its  actual  presence. 

The  full  examination  thus  occasionally  required  involves  the  fol- 
lowing considerations  : 

1.  The  condition  of  the  circulation. 

2.  The  condition  of  the  respiration. 

3.  The  condition  of  the  muscular  system. 

4.  Changes  in  the  eve. 

The  Condition  of  the  Circulation. — Following  from  the 
principle  stated  at  the  beginning  of  this  chapter,  that  life,  or  the  possi- 
bility of  restoration  of  a  vital  function,  remains  longest  in  that  organ 
where  molecular  or  cellular  activity  is  most  persistent,  the  condition  of 
the  heart  and  circulation  becomes  the  most  unportant  inquiry  in  the 
determination  of  death.  In  man  the  heart's  action  nearly  always  con- 
tinues after  respiration  has  ceased,  the  chief  exceptions  being  seen  in 
deaths  from  poisoning  by  cardiac  depressants.  The  heart  of  a  decapi- 
tated criminal  has  been  observed  to  beat  for  fifteen  minutes.  In  execu- 
tions by  hanging  and  electricity  in  this  country  the  pulse  commonly 
persists  some  minutes  after  breathing  has  ceased.  In  the  asphyxia  of 
new-born  infants  comparatively  little  attention  need  be  paid  to  the 
absence  of  breathing  so  long  as  the  heart  beats  plainly.  The  anatomic 
basis  of  this  life  tenacity  of  the  heart  is  found  in  the  high  development 
and  automatic  character  of  the  cardiac  nervous  apparatus. 

An  important  factor  affecting  the  possibility  of  resuscitation  after 
failure  of  the  heart  is  the  coagulation  of  the  blood,  ^^'hen  large  parietal 
thrombi  f  )rm  during  the  last  moments  of  life  the  vitality  of  the  heart 
muscles  is  of  little  avail  in  any  attempt  to  restore  the  circulation.  In 
many  instances  of  sudden  death,  and  in  the  last  stages  of  wasting  dis- 
eases, when  the  coagulation  of  the  blood  is  feeble,  it  is  possible,  by 
active  stimulation,  to  elicit  a  few  heart-beats  or  even,  in  the  latter  case, 
to  prolong  life  for  some  hours. 

The  only  safe  method  of  determining  the  presence  or  absence  of  the 
heart's  action   is  l)y  careful,  prolonged,  and  repeated  auscultation,  with 


108  THE    SIGNS    OF    DEATH. 

entire  freedom  from  all  distracting  noises,  and  it  may  be  confidently 
expected  that  when  these  conditions  are  properly  secured,  the  stethoscope 
will  give  entirely  trustworthy  information  in  every  case.  Such  favor- 
able conditions  being  rarely  found,  the  examiner  has  often  to  rely  upon 
the  unaided  ear  in  auscultation,  and  the  result  of  the  examination  may 
not  be  convincing. 

Further,  as  is  well  known,  in  very  corpulent  persons  the  normal 
heart-sounds  may  be  rather  indistinct  because  of  the  thickness  of  the 
chest-wall.  Some  pathologic  conditions  may  increase  the  natural  diffi- 
culties of  the  case.  In  chronic  interstitial  or  fatty  myocarditis  the 
heart-sounds  are  usually  feeble  and  may  be  indistinct.  With  pericardial 
effusions  the  heart-sounds  may  be  very  obscure  ;  while  cases  of  trans- 
position of  the  viscera  or  of  displacement  of  the  heart  from  chronic 
inflammation  of  the  lungs  are  occasionally  encountered. 

When  the  results  of  auscultation  remain  unsatisfactory,  resort  may 
be  had  to  some  of  the  mmierous  tests  devised  to  demonstrate  the  con- 
dition of  the  peripheral  circulation.  In  using  these  tests  it  must  be 
admitted  that  they  are  necessarily  less  reliable  than  direct  auscultation, 
for  the  reason  that  the  peripheral  circulation  may  be  practically  at  a 
standstill,  although  the  heart  is  still  feebly  beating. 

One  of  the  most  reliable  of  these  tests  is  that  suggested  by  Magnus.^ 
If  a  ligature  is  applied  to  a  finger  or,  if  the  skin  is  horny,  to  a  lobe  of 
the  ear,  so  as  to  cut  oif  the  venous  channels  without  occluding  the 
arteries,  when  the  circulation  has  not  entirely  ceased  the  distal  area  will 
become  gradually  engorged  with  blood,  and  its  color  will  become  first 
reddish  and  finally  cyanotic.  At  the  same  time  the  capillary  anemia 
about  the  ligature  produces  a  white  ring  plainly  marked  oif  from  the 
surrounding  area  of  congestion.  The  success  of  this  test  will  naturally 
depend  on  the  exact  adjustment  of  the  pressure  so  as  to  compress  the 
veins  without  occluding-  the  arteries. 

It  has  been  stated  here  that  if  wet  cups  are  applied  to  the  skin  a 
few  hours  after  death,  no  blood  will  flow,  while  if  the  circulation  still 
feebly  persists,  blood  will  readily  appear  under  the  cup.  The  result  in 
this  case  depends  upon  the  condition  of  the  blood  in  the  small  vessels 
incised,  which  is  well  known  to  be  variable.  Wounds  have  been  found 
to  bleed  for  two  or  three  hours  after  death. 

The  diaphanous  test  of  death  has  been  the  subject  of  considerable 
recent  discussion.  It  has  long  been  known  that  if  the  hand  of  a  living 
person  be  held  before  a  strong  light,  it  almost  invariably  appears  scarlet 
or  very  red,  while  after  death  the  appearance  of  the  hand  under  similar 
conditions  is  usually  opaque.  It  has  been  claimed  that  opacity  of  the 
hand  after  death  is  caused  principally  by  the  coagulation  of  the  blood, 
for  in  cases  in  which  the  blood  has  remained  fluid  in  the  large  veins  this 
life-like  scarlet  color  has  been  demonstrated  after  death.  But  the 
opacity  indicating  death  has  been  observed  in  syncope,  when  the  blood 
must  always  remain  fluid.  While  the  exact  conditions  determining 
the  appearances  in  the  diaphanous  test  must,  therefore,  be  regarded  as 

'    Virchow's  Arc.hiv,  1872,  Bd.  Iv. 


SPECIAL    SIGNS    OF    DEATH.  109 

uukiiown,  the  test  has  shown  itself",  by  Un\o^  exj)erience,  to  give  valuable 
corroborative  evidence  of  death. 

The  Condition  of  the  Respiration. — Tiie  complete  and  pro- 
longed absence  of  resj)iration  is  a  sign  of  death  second  in  importance 
onlv  to  the  cessation  ol'  the  heart's  action.  In  a  few  conditions  res])ira- 
tion  may  continue  for  a  short  time  after  the  heart  has  ceased  beating  ;  a 
reversal  of  the  usual  order  of  events  is  probal)ly  most  often  seen  in 
heart  failure  during  anesthesia.  But  the  respiratory  function  is  much 
less  capable  of  withstanding  unfavorable  conditions  than  is  the  heart's 
action.  When  respiration  ceases  suddenly,  while  tiie  vitality  of  tlie 
heart  is  unim])aired,  the  resulting  asphyxia  is  marked  l)v  great  venous 
congestion.  When  the  asphyxia  is  gradual,  as  sometimes  occurs  in 
croup  and  in  laryngeal  stenosis  by  tumors,  the  heart's  force  is  often 
much  reduced  bv  the  continued  lack  of  oxvgen  or  bv  other  causes,  and 
the  patient  may  die  with  marked  pallor  instead  of  cyanosis.  This 
imjwrtant  fact  is  frequently  overlooked,  and  the  writer  has  seen  patitaits 
with  laryngeal  stenosis  die,  with  pallor,  while  the  surgeon,  with  instru- 
ments ready,  was  waiting  for  the  appearance  of  cyanosis  before  per- 
forming tracheotomy.  The  pallor  of  a  body  or  corpse  is,  therefore,  no 
certain  indication  that  respiratory  failure  has  not  been  chiefly  answer- 
able for  death. 

There  is  much  variation  in  the  length  of  time  required  for  com{)lete 
lack  of  air  to  produce  fatal  asphyxia.  Most  healthy  persons  have 
difficultv  in  holding  the  breath  for  a  full   minute. 

In  rare  instances,  usually  after  long  training,  the  breath  has  been 
held  for  four  or  five  minutes,  a  period  which  will  (Ordinarily  suffice  to 
render  most  persons  unconscious.  Death  has  repcatetlly  occurred  after 
submersion  in  water  for  five  minutes,  although  resuscitation  has  been 
successful  after  the  body  has  lain  in  water  one  hour.  As  in  the  case 
of  the  circulation,  the  possibility  of  restoring  respiration  depends  on 
the  vital  condition  of  the  respiratory  center.  Circumstances  are  most 
favorable  when  asphyxia  occurs  in  health,  less  so  when  ether,  chloro- 
form, or  carbonic  oxids  have  poisoned  the  nervous  system  or  altered 
the  blood,  and  least  so  in  death  from  general  diseases. 

In  catalepsy,  as  before  mentioned,  the  breathing  may  temporarily 
cease  or  become  so  superficial  as  to  escape  detecti(on.  In  severe  opium 
poisoning  it  should  be  remembered  that  the  respiration  may  fall  to  two 
or  three  a  minute,  and  may  be  so  superficial  as  to  escape  notice  unless 
careful  and  continuous  examination  is  made  over  a  period  of  some 
minutes.  In  profound  shock  the  respiration  may  be  very  superficial. 
In  the  Cheyne-Stokes  variety  of  respiration,  which  has  been  observed 
at  nearly  all  ages  and  in  a  great  variety  of  conditions,  the  interval 
between  the  deep  and  easily  recognized  respirations  may  be  as  long  as 
two  minutes. 

When  it  seems  probable,  from  external  signs,  that  respiration  has 
ceased,  this  fact  may  best  be  finally  determined  by  the  following  pro- 
cedures : 

1.  Careful  and  prolonged  auscultation  may  be  made  over  the  chest, 


110  THE -SIGNS    OF    DEATH. 

trachea,  and  larynx,  but  very  feeble  respiratory  movements  may  pro- 
duce no  appreciable  sound  in  these  localities. 

2.  It  may  be  possible  to  demonstrate  that  warm  moist  air  is  being 
exhaled  from  the  nostrils  by  holding  a  mirror  before  the  face,  on  which 
any  moisture  passing  out  of  the  nostrils  will  condense  in  visible  form. 
But  according  to  Tidy,  a  mirror  placed  over  the  mouth  of  a  hibernating 
animal  is  not  dulled,  and  other  instances  are  recorded,  of  which  Colonel 
Townsend's  is  one,  in  M'hich  this  test  failed.  It  may  be  recommended 
that  the  mirror  used  in  this  test  be  made  very  cold,  in  order  more 
effectually  to  condense  any  moisture  present. 

3.  The  presence  of  very  faint  currents  of  air  may  be  detected  by 
the  movements  of  cotton  fibers  place  over  the  mouth  and  nostrils. 

4.  Slight  movements  of  the  chest-wall,  ordinarily  invisible,  may  be 
detected  by  carefully  observing  the  surface  changes  of  a  vessel  of  water 
or  mercury  placed  itpon  the  chest. 

It  is  not  probable  that  the  two  last-mentioned  procedures  will 
demonstrate  any  respiratory  movements  not  detected  l>y  the  first  and 
second  methods,  and  when  repeated  and  prolonged  auscultation  can  be 
properly  performed,  except  in  very  rare  instances  it  may  be  expected 
to  give  reliable  and  final  evidence  of  the  presence  or  absence  of  respira- 
tory movements. 

The  Condition  of  the  Muscular  System. — Complete  mus- 
cular relaxation  is  usuallv  an  essential  condition  in  death,  although  its 
presence  is,  of  course,  no  indication  of  the  reality  of  death.  Cataleptic 
rigidity  has,  liowe\'er,  been  observed  to  pass  without  interruption  into 
rigor  mortis,  and  nimaerous  instances  are  recorded  in  which  rigor 
mortis  has  followed  immediately  upon  sudden  death,  usually  in  states 
of  mental  excitement  or  active  muscular  exertion.  In  the  majority  of 
cases,  especially  of  those  in  which  the  reality  of  death  is  questioned, 
there  is  a  considerable  ])eriod  of  complete  nniscular  relaxation.  During 
this  period  the  contractility  of  muscle  is  not  lost  for  some  time,  and,  as 
will  be  shown  later,  its  persistence  is  no  indication  of  life.  If,  how- 
ever, the  muscles  fail  to  respond  to  electric  stimuli,  barring  some 
forms  of  nervous  disease  it  mav  confidentlv  be  stated  that  death  has 
occurred. 

The  Facial  Appearance. — As  a  combined  result  of  the  failure  of 
respiration  and  circulation  and  the  loss  of  muscular  tone  certain  char- 
acteristic alterations  in  the  countenance  occur  Avliich  have  long  been 
described  as  the  facies  Hippocratica.  In  this  condition  the  appearances 
may  be  referred  chiefly  to  the  anemia  of  the  tissues  and  the  loss  of  mus- 
cular tone.  The  skin  is  dry  and  livid,  the  eyes  are  shrunken,  the  drawn 
muscles  cause  the  nose,  cheek,  and  chin  to  appear  unnaturally  promi- 
nent, while  the  lips  are  pale  and  flaccid.  The  facies  Hippocratica,  while 
in  mnny  cases  a  convincing  sign  of  death,  has  very  little  positive  value, 
being  usually  absent  in  cases  of  sudden  death,  persisting  generally  only 
a  short  time  after  death,  appearing  in  striking  form  in  the  dying  or 
even  in  cases  of  extreme  terror.  The  cause  and  manner  of  death  have 
mueli  influence  in  determining  the  appearance  of  the  face  of  the  corpse. 


SPECIAL    SIGNS    OF    PEATII.  Ill 

Painful  death  usually  leaves  abundant  traces  of  the  previous  mental 
condition  of  the  individual.  After  sudden  death  the  facial  expression 
present  immediately  before  is  frecpiently  preserved  in  recognizable  form. 

Changfes  in  the  Hye. — No  ])ositive  signs  have  as  yet  been 
elicited  in  the  eye  to  prove  the  reality  of  death  soon  after  its  occurrence. 
The  conjunctiva  is  insensitive,  and  a  thin  film  of  nuicus  usually  gathers 
over  the  cornea,  which  thereby  loses  its  luster,  but  each  of  these  condi- 
tions may  be  observed  occasionally  in  the  living,  and  the  latter  is  not 
an  invariable  acconi])aninient  of  death.  It  has  been  noted  after  death 
from  apoi)lexv  and  from  poisoning  by  prussic  acid  or  carbonic  oxids 
that  the  eoniunctiva  lone;  remains  shinv  and  the  eveball  clastic.  The 
gases  developed  by  putrefaction  may  distend  the  vessels  of  the  orbit  and 
maintain  the  prominence  of  the  eyeball  and  the  natural  color  of  the 
conjunctiva.  Cadaveric  changes  of  color  of  the  conjunctiva  are  some- 
times observed  very  soon  after  death. 

The  iris  is  flaccid,  and  the  pupil  is  usually  moderately  dilated  and 
irresponsive  to  strong  light,  although  solutions  of  atropin  or  of  eserin 
may  alter  the  size  of  the  pupil  for  at  least  a  half-liour  after  death  (Tidy). 
The  shape  of  the  pupil  may  also  be  altered  by  appropriate  pressure  on 
the  relaxed  fundus,  but  this  efiTect  has  been  noted  to  a  lesser  degree 
during  life. 

A  marked  loss  of  elasticity  of  the  eyeball  is  not  usually  noticed  until 
a  few  hours  after  death,  and  must  be  reckoned  among  the  cadaveric 
changes,  but  occasionally  the  eyeball  is  foimd  distinctly  softened  imme- 
diatelv  after  death.  The  same  condition  has  been  observed  before 
death,  however,  and  its  presence  is  not  of  decisive  import  in  the  diag- 
nosis. Nicati  ^  has  invented  an  ophthalmotonometer,  from  the  use  of 
which  he  claims  to  have  demonstrated  that  the  physiologic  limits  of  the 
tension  of  the  eyeball  vary  between  14  and  25  grams;  with  the  cessa- 
tion of  the  heart's  action  it  falls  to  12  grams,  then  irregularly  to  1  to  3 
grams ;  and  two  hours  after  death  it  sinks  to  zero. 

Some  indications  of  interest  and  value  may  be  obtained  from  ophthal- 
moscopic examination.  It  is  stated  by  Poncet,  quoted  by  Tidy,  that 
the  anemia  of  the  fundus  after  death  is  very  evident  in  the  yelloAvish- 
white  color  which  replaces  the  yellowish-red  of  the  living  condition. 
Gayet^  says  that  after  death  the  vessels  of  the  fundus  are  completely 
emptied  in  the  optic  disc,  and  for  some  distance  about  it,  while  in  the 
remainder  of  the  fundus  the  vessels  remain  filled  with  blood.  Pneuma- 
tosis of  the  veins  of  the  fundus  is  regarded  by  Bouchet  '■''  as  a  relial)le 
and  immediate  sign  of  death.  This  condition  is  su])])osed  to  be  pro- 
duced by  the  disengagement  of  the  gases  of  the  blood  in  the  form  of 
minute  bubbles,  plainly  visible  in  the  l)roken  column  of  blood  in  the 
veins.  It  would  seem  that  the  condition  of  the  vessels  of  the  fundus 
must  depend  much  u])on  the  position  of  the  body  and  the  manner  of 
death. 

^  Lancet,  Feb.  17,  1894.  ^  Atmales  d' nmlistiques,  .Jan.,  1875. 

=*  Gaz.  des  Hopitaux,  Mar.  10,  1874. 


112  THE    SIGNS    OF    DEATH. 

CADAVERIC  CHANGES. 

While  none  of  the  signs,  as  outlined  above,  can  of  itself  be  regarded 
as  a  conclusive  proof  of  death,  it  cannot  be  admitted  at  the  present  day 
that  in  the  hands  of  a  competent  person  the  complete  examination  of 
the  body,  even  Avith  reference  to  these  so-called  "  inconclusive  signs," 
can  ever  lead  to  a  false  diagnosis  of  death.  Yet  none  of  the  phenomena 
thus  far  considered  gives  any  indication  of  the  length  of  time  that  life 
has  been  extinct.  The  presence  of  cadaveric  changes,  however,  is  con- 
clusive proof  of  the  reality  of  death,  and  the  sequence  of  these  changes 
furnishes  important  evidence  as  to  the  time  of  death.  It,  therefore, 
becomes  necessary  to  study  in  detail  the  process  of  cadaveric  changes 
in  the  body. 

The  Bxtinction  of  Animal  Heat. — The  cooling  of  the  body, 
considered  as  a  sign  of  death,  cannot  be  regarded  as  decisive  evidence 
until  the  temperature  has  fallen  fifteen  or  twenty  degrees,  for  rectal 
temperatures  of  94°  F.  have  been  observed  in  the  algid  stage  of  cholera, 
and  much  lower  temperatures  (76°  F.,  Zicgler)  are  not  incompatible 
with  life  under  long  exposure  to  cold. 

The  rate  of  cooling  is  affected  by  such  a  variety  of  circumstances 
tliat  in  the  majority  of  cases  it  is  impossible,  from  the  temperature  of 
the  body,  to  draw  a  positive  inference  as  to  the  time  of  death.  Thus 
it  is  possible  for  the  body  to  have  at  death  a  temperature  of  120°  F. 
after  death  from  sunstroke,  or  of  80°  F.  after  death  from  cold ;  in  the 
former  case  several  hours  must  elapse  before  the  body  could  cool  to  the 
temperature  observed  at  death  in  the  latter  case.  Moreover,  a  high 
antemortem  temperature  may  be  long  maintained  or  even  increased 
after  death  from  cholera,  yellow  fever,  small-pox,  tetanus,  rheumatism, 
nephritis,  and  from  some  diseases  of  tiie  l)rain  and  meninges. 

This  postmortem  elevation  of  temperature  has  been  vari- 
ously attril)uted  to  f;iilure  of  the  circulation,  by  which  the  blood  is 
aerated  and  cooled,  to  failure  of  the  heat-regulating  center,  to  excessive 
metabolic  processes  during  and  after  death,  and  to  the  chemical  changes 
of  decomposition.  Distinct  postmortem  elevations  of  temperature  have 
been  observed  from  the  diseases  just  mentioned,  and  may  be  expected 
to  occur  when  death  has  been  preceded  by  violent  muscular  spasm. 

In  general,  the  cooling  of  the  body  is  more  rapid  after  chronic  and 
wasting  diseases,  when  the  loss  of  heat  begins  in  the  extremities  before 
death  ;  while  after  acute  diseases  or  sudden  death  the  jirocess  of  cooling 
is  usually  much  slower.  The  rate  of  cooling  is  j)rincij)ally  affected  by 
external  conditions,  the  temperature  of  the  surrounding  air  or  water, 
and  the  clothing  of  the  body.  The  bodies  of  old  and  emaciated 
subjects  cool  much  more  rapidly  than  those  of  large  and  corpulent 
adults. 

Notwithstanding  the  wide  variations  in  the  rapidity  of  the  cooling 
process  thus  indicated,  there  exists  a  large  class  of  cases  in  which  ordi- 
nary conditions  prevail  and  in  which  the  extinction  of  animal  heat 
proceeds  more  uniformly.     The  ordinary  course  of  postmortem  cooling 


CADAVERIC   CHANGES.  113 

has  been  made  the  subject  of  several  extended  observations,  undertaken 
with  a  view  to  determining-  the  relation  ot"  the  temperature  of  the 
corpse  to  the  })eriod  of  death.  Taylor  and  Wilks '  made  about  200 
observations  on  the  external  temperature  of  bodie^j  removed  from  the 
wards  of  Guy's  Hospital  and  allowed  to  eool  in  the  dead-house,  where 
the  temperature  ranged  between  ."i8°  and  09°  F.  The  temperatures 
were  taken  upon  the  skin  of  the  abdomen,  at  intervals  during  the  lirst 
twenty  hours  after  death,  but  the  temperatures  innnediately  after  death, 
and  for  the  first  two  hours  thereafter,  were  not  ol^served.  In  spite  of 
these  deficiencies  in  technics  and  in  the  completeness  of  the  observa- 
tions, their  results  showed  conclusively  that  under  ordinary  circum- 
stances the  cooling  of  the  body  proceeds  very  slowly,  the  surface  tem- 
perature not  approaching  that  of  the  surrounding  air  for  at  least  twenty 
hours  after  death.  In  no  case,  even  after  twenty  hours,  did  the  tem- 
perature of  the  body  fall  as  low  as  that  of  the  air.  Of  76  observations 
in  which  the  temperature  Avas  taken  two  to  three  hours  after  death,  the 
maximum  found  was  94°  F.,  the  minimum,  ()0°  F.,  and  the  average, 
77°  F.  The  average  temperatures  found  at  diiferent  periods  were,  at 
two  to  three  hours,  77°  F.;  at  four  to  six  hours,  74°  F.;  at  six  to 
eight  hours,  70°  F.;  at  twelve  or  more  hours,  69°  F.  It  ap])ears, 
therefore,  that  the  cooling  proceeds  more  rapidly  soon  after  death,  and 
more  slowly  as  the  tem]ierature  of  the  body  approaches  that  of  the  air. 
The  minimum  temperature  found  two  hours  after  death  was  60°  F.,  and 
twelve  hours  after  death  56°  F.,  results  so  nearly  equal  as  to  prohibit 
the  application  of  any  fixed  rule  regarding  the  external  temperature  of 
the  body  at  diiferent  periods  after  death. 

Niederkorn  made  135  observations  on  the  axillary  temperature  of 
bodies  subjected  to  ordinary  conditions,  with  the  following  average 
results,  Fahrenheit  scale  : 

Temperature  of  body    .         Two  to  four         Four  to  six  Six  to  eight      Eight  to  twelve 

after  tleatli.  hours.  liours.  hours.  liours. 

Maximum 100.4°  98.2°  d'xZ^  100.4° 

Minimum 89.  G°  80.6°  70.5°  62.  G° 

Average 96.9°  90.2°  81.7°  77.9° 

As  is  to  be  expected,  the  course  of  the  axillary  temperature  gives, 
therefore,  more  accurate  indications  of  the  time  that  has  elapsed  since 
death  than  does  that  of  the  surface  temperature  of  the  abd(5men. 

Of  internal  temperatures,  Taylor  and  \yilks  recortl  instances  of 
76°  F.  seventeen  hours  after  death,  and  of  85°  F.  ten  hours  after 
death.  Niederkorn  found  that  the  rectal  temperattn*e  in  6  cases 
averaged  90.6°  F.  six  to  eight  hours  after  death,  and  S9."2°  F.  twelve 
to  fourteen  hours  after  death.  Letheby,  (pioted  l)y  Tidy,  found  the 
rectal  temperature  to  be  18°  F.  and  the  axillary  tem])eratnre  14°  F. 
higher  than  that  of  the  air  as  long  as  twenty  to  twenty-four  hours  after 
death.  The  rate  of  cooling  has  been  found  by  Goodhardt'  during 
the  first  three  hours  to  be  3.5°  F.  in  the  robu.'^t  and  4.5°  F.  in  the 
emaciated  ;  during  the  second  three  hours,  3°  F.  in  both  ;  and  about 

1  Gmfs  Hospifal  Reports,  1803,  p.  184.  ^  /^j,;.^  1870. 

Vol.  I.— 8 


114  THE    SIGNS    OF    DEATH. 

1  °  F.  an  hour  as  the  temperature  of  the  body  approaches  that  of  the 
air. 

It  is  very  apparent  from  the  incompleteness  of  the  studies  cited  that 
it  is  impossible  at  the  present  time  to  determine  accurately  the  time  of 
death  from  observations  on  the  temperature  of  the  corpse.  In  order  to 
reach  any  conchision  of  value  it  is  necessary  to  consider  the  cause 
of  death,  the  antemortem  rise  of  temperature,  the  condition  of  the  sur- 
rounding medium,  and  all  circumstances  favorable  or  unfavorable  to  the 
extinction  of  animal  heat.  It  seems  probable  that  observations  on  the 
course  of  the  rectal  temperature  in  cadavers,  together  Avith  a  study  of 
the  causes  affecting  postmortem  internal  temperature,  might  secure 
much  valuable  information  in  regard  to  this  rather  important  medico- 
legal inquiry. 

Changes  in  the  Muscular  System. — In  the  majority  of 
mstances  death  is  followed  by  a  considerable  but  very  variable  period 
of  muscular  relaxation.  During  "this  period,  which  does  not  usually 
continue  longer  than  two  or  three  hours,  although  it  may  be  moderately 
prolonged,  the  muscles  retain  their  mechanical  and  electric  irritability, 
and  may  be  made  to  contract  with  some  force  by  repeated  blows  from 
the  hand  or  by  the  application  of  the  electric  current.  Rosenthal ' 
examined  the  electric  irritability  of  the  muscles  and  nerves  of  20  bodies 
dead  from  various  causes,  using  the  continuous  and  interrupted  currents. 
He  found  that  the  electric  reaction  of  the  muscles  outlasts  that  of  the 
nerve-trunks,  and  is  longest  retained  in  the  muscles  farthest  removed 
from  the  cercbros]iinal  axis.  He  1)eli('yes  and  cites  a  striking  case  to 
show  that  the  loss  of  electric  irritability  in  all  the  muscles  is  a  very 
positive  sign  of  death,  and  in  the  absence  of  other  reliable  signs  may 
be  of  decisiye  value  in  diagnosis. 

The  loss  of  electric  reaction  in  a  single  muscle  or  group  of  muscles 
cannot  be  accepted  as  evidence  <  f  death,  as  this  condition  may  be  seen 
during  life  in  portions  of  the  muscular  system  under  a  variety  of  cir- 
cumstances. After  complete  muscular  exhaustion  the  electric  reaction 
of  some  muscles  may  be  largely  or  entirely  suspended.  Diseases  of 
the  muscles,  such  as  pseudohypertrophic  paralysis,  or  of  the  brain,  cord, 
and  peripheral  neryes,  may  destroy  electric  excitability.  Certain  muscle 
poisons,  as  tlie  nitrites,  may  completely  suspend  muscular  irritability. 
Long-continued  ex}>osure  to  cold  at  28°  to  38°  F.  suspends  muscular 
excitability,  while  the  continued  action  of  heat  of  120°  F.  coagulates 
myosin  and  destroys  contractility.^ 

The  degree  of  postmortem  muscular  irritability  may  be  of  much 
assistance  in  determining  the  time  of  death.  ]\Iuscular  contractility  is 
commonly  lost  within  three  to  six  hours  after  death,  and  no  case  is 
recorded  in  which  it  persisted  twenty-four  hours.  Animus  ^  states  that 
the  diaphragm  and  tongue  first  lose  their  irritability  ;  the  facial  muscles 
retain  this  property  for  two  to  three  hours ;  the  extensors  of  the  limbs 

1  Jonrnnl  of  Anaiomy  and  Physiology^  Nov.,  1872. 

2  Kichardson's  Croonian  Lectm-es,  1873.  =*  Le  Mouvement  Med.,  Feb.,  1873. 


CADAVERIC    CHANGES.  115 

for  four  hours ;  the  muscles  of  the  trunk  for  five  to  six ;  and  the  muscles 
of  the  abdominal  wall  some  time  longer. 

According  to  Xyster,  tlie  loss  of  nuiscular  irrital)iHty  occurs  in  the 
following  order — left  ventricle,  intestines,  stomach,  bladder,  right  ven- 
tricle, esophagus,  iris,  muscles  of  trunk,  muscles  of  up])er  and  lower 
extremities,  and,  lastly,  the  muscles  of  the  heart.  The  cause  and 
manner  of  death  atfect  the  persistence  of  mnscidar  ii-ritabilitv,  as 
pointed  out  by  Tidy  from  the  observations  conducted  at  La  Charite, 
where  it  was  found  that  after  death  from  peritonitis,  nuiscular  con- 
tractility commonly  disappeared  in  three  hours ;  from  phthisis  and 
carcinoma,  in  three  to  six  hours  ;  from  cardiac  disease  and  hemorrhage, 
in  nine  hours ;  from  paralysis,  in  twelve  hours ;  and  from  pneumonia, 
in  ten  to  fifteen  hours. 

The  possibility  of  spontaneous  muscular  movements  during  the 
period  of  muscular  irritability  seems  to  be  fiirly  well  attested.  To 
such  spontaneous  contraction  may  sometimes  be  referred  the  closing  of 
the  lower  jaw  after  death.  Tidy  ^  reports  having  observed  movements 
of  pronation,  supination,  and  flexion  in  a  body  dead  seven  hours,  during 
the  cholera  epidemic  of  18(30.  So  far  as  he  could  judge,  they  were 
absolutely  spontaneous.  Similar  movements  have  been  observed  by 
others  after  death  from  cholera  and  yellow  fever,  but  in  judging  this 
evidence  it  is  to  be  remembered  that  rigor  mortis  ])roduces  a  shortening 
of  the  muscle,  with  results  sometimes  identical  with  those  of  true  con- 
traction. 

Rig'Or  Mortis. — The  period  of  muscular  relaxation  and  contrac- 
tility is  commonly  succeeded  by  a  period  of  muscular  rigidity,  or  rigor 
mortis.  This  phenomenon  is  produced  by  the  formation  of  myosin, 
probably  through  the  action  of  a  ferment  upon  a  hypothetic  proteid, 
mifosiiiOf/en  (Kiihne).  Of  the  properties  of  myosin,  one  is  of  S])ecial 
importance  here,  namely,  its  capability  of  being  transformed  into 
syntonin  by  the  action  of  dilute  acids.  To  this  transformation,  under 
the  influence  of  lactic  acid,  is  probably  due  the  disa]i]iearance  of  rigor 
mortis  as  putrefiiction  begins  in  the  body,  although  it  is  probable  that 
the  small  quantity  of  pepsin  found  in  nuiscle  may  also  have  a  con- 
sideralole  part  in  dissolving  myosin  and  causing  the  disappeanmce  of 
rigidity.  After  the  loss  of  rigidity,  peptones  and  other  products  of 
gastric  digestion  are  found  in  the  substance  of  muscle  (Neumeister). 

In  addition  to  mijofiin,  which  coagulates  at  56°  C.  (132.8°  F.), 
muscle  in  a  condition  of  rigor  mortis  contains  another  allied  substojice, 
mmcudn,  coagulating  at  47°  C.  (11(3,6°  F.),  to  the  formation  of  which 
is  due  the  rigidity  produced  when  fresh  muscle  is  heated  to  47°  C. 
(116.6°  F.)  (Halliburton).  Ordinary  fresh  healthy  muscle  is  ncMitral  in 
reaction  or  has  a  slight  tendency  toward  alkalinity.  It  becomes  acid 
during  rigor  mortis,  from  the  development  of  lactic  acid,  and  finally 
alkaline,  fnmi  the  develoj)ment  of  anunonia  during  decomposition 
(Neumeister).  Actively  tetanized  muscle  becomes  slightly  acid  in  reac- 
tion, and  the  total  quantity  of  lactic  acid  finally  produced  in  such  a 

^  Legal  Medicine,  i.,  p.  55. 


116  THE    SIGNS    OF    DEATH. 

muscle  is  greater  than  usual.  The  reaction  of  heart  muscle  is  slightly 
acid  (Kiihne,  Yoit).  The  appearance  of  rigor  mortis  does  not  indicate 
the  death  of  a  muscle,  for  it  has  been  shown  that  if  a  current  of 
alkaline  arterial  blood  be  passed  through  a  rigid  muscle,  it  becomes 
flaccid  and  capable  of  contraction  under  electric  stimulus  (Brown- 
Sequard).  The  similarity  in  the  chemical  processes  occurring  in  nuiscle 
during  contraction  and  during  the  formation  of  rigor  mortis  has  been 
j)ointed  out  by  Hermann,  who  regards  rigor  mortis  as  only  a  modified 
form  of  true  contraction. 

So  far  as  is  known,  the  phenomena  of  rigor  mortis  in  inyoluntary 
muscle  are  similar  to  those  of  voluntary  muscle.  The  heart  often 
becomes  rapidly  rigid  and  of  distinctly  acid  reaction.  In  the  stomach 
and  uterus  rigor  has  been  observed,  but  in  other  situations  it  is  difficult 
to  determine  the  condition  of  smooth  muscle,  and  rigor  has  never  been 
satisfactorily  demonstrated  (Halliburton). 

Period  of  Onset  of  Rigor  Mortis. — From  various  observations  it 
appears  that  rigidity  affects  some  groups  of  muscles  usually  within  the 
first  two  hours  after  death.  Niederkorn  found  that  in  all  of  113  cases 
one  or  more  joints  became  rigid  within  this  period.  In  the  heart,  rigor 
commonly  appears  at  the  end  of  the  first  hour,  and  the  increased  thick- 
ness and  firnmess  thus  resulting,  especially  if  found  at  a  time  when 
other  muscles  are  flaccid,  may  lead  to  an  incorrect  diagnosis  of  cardiac 
hypertrophy.  Similarly,  the  rapid  return  of  extreme  flaccidity  in  this 
organ  may  give  the  impression  of  cardiac  atrophy  or  degeneration. 

The  difference  in  time  required  for  the  apjiearance  of  rigor  mortis 
in  the  various  muscles  probably  depends  upon  some  difference  in  their 
chemical  condition,  the  nature  of  which  is  undetei-mined.  A  numl)er 
of  established  facts  may  be  mentioned  as  indicating  that  the  rapidity 
of  its  onset  is  partly  favored  by  a  diminished  alkalinity  of  the  muscle 
substance.  The  left  ventricle,  of  which  the  reaction  is  slightly  acid,  is 
usually  the  first  muscle  to  become  rigid.  In  a  number  of  conditions 
attended  with  great  muscular  activity,  as  overexertion,  tetanus,  strych- 
nin poisoning,  which  diminish  the  alkalinity  of  muscle,  death  is  very 
soon  followed  by  rigor. 

Beginning,  then,  in  one  or  more  groups  of  muscles,  rigor  mortis  is 
usually  complete  or  reaches  its  height  in  one  to  two  hours  after  its  onset. 
In  two  of  Xiederkorn's  cases  it  was  complete  in  two  hours  after  death. 
Riscor  mav,  however,  be  very  lona;  delayed  or  may  be  so  sliaht  as  to 
escape  notice.  A  slow  onset  of  rigidity  may  be  expected  after  death 
in  conditions  of  full  muscular  vigor,  as  by  apoplexy  or  by  injuries  to 
the  brain  or  medulla.  The  bodies  of  decajiitated  criminals  have  been 
known  to  remain  limp  for  several  hours,  death  from  hemorrhage  being, 
perhaps,  the  commonest  cause  of  delayed  rigor.  Amputated  limbs 
usually  remain  flaccid  for  many  hours.  After  death  from  asphyxia, 
especially  of  new-born  infants,  rigor  is  often  long  delayed  and  of 
diminished  intensity.  Rigidity  is  delayed  in  death  from  acute  irritant 
poisons,  but  a  rapid  onset  is  favored  in  poisoning  by  quinin,  caffein, 
digitalis,  veratrin,  hydrocyanic  acid,  ether,  chloroform,  and  small  doses 


CADAVERIC   CHANGES.  117 

of  strvclniin.     As  cold  jirevents  the  action  of  tlic  niyosin-producing  fer- 
ment, rin'oi"  is  of  late  occurrence  after  tleath  from  tiiis  cause. 

A  rapid  onset  of  rigor  mortis,  which  is  of  rather  greater  medicolegal 
interest  than  its  delayed  appearance,  may  be  expected,  generally,  in 
conditions  marked  by  great  muscular  exhaustion.  For  the  fullest  pro- 
duction of  rigidity,  however,  a  ])owerfu.l  muscular  system  is  required. 
As  myosin  and  musculin  coagulate  at  o(i°  and  47°  C.  respectively,  a 
high  temperature  at  death  naturally  favors  the  proni]it  onset  of  rigidity. 
Apart  from  the  very  early  or  imnuHliate  rigidity  of  a  single  muscle,  as 
of  the  heart,  eyelids,  and  face,  which  may  considerably  ])recede  a  similar 
change  throughout  the  body,  general  muscular  rigidity  sets  in  early 
after  death  from  long-continued  fevers,  pulmonary  tubercidosis,  cholera, 
hvdrophol)ia,  and  poisoning  by  large  doses  of  strychnin.  Com[)lete 
rio-iditv  has  often  been  noted  vhile  the  body  was  still  warm.  Brown- 
Seqnard  reports  a  case  of  beginning  rigor  while  the  heart  was  still 
beating,  at  death  from  typhoid  fever.  Stiffenmg  of  the  eyelids  not 
infrequently  occurs  while  the  heart's  action  continues  (Guy).  The 
instantaneous  onset  of  rigor  mortis  occurs  so  frequently  after  sudden 
deatii  during  violent  muscular  exertion,  and  the  immediate  fixation  of 
the  body  in  the  exact  attitude  and  expression  at  the  moment  of  death 
has  been  so  life-like,  that  many  remarkable  instances  of  this  sort  have 
become  matters  of  common  reference.  It  is  reported  that  at  tlie  battle 
of  Antietam  Creek  the  bodies  of  some  Union  soldiers  killed  in  the 
exhaustino;  charge  near  the  bridoe  were  found  rigidlv  set  in  the  act  of 
climbing  an  obstructing  fence,  or  crouched  behind  the  fence  in  the  act 
of  firing,  while  the  intense  excitement  of  the  charge  was  plamly  visible 
in  the  fixed  expression  of  the  face.  A  startling  incident  of  the  charge 
at  Balaklava  is  recorded  by  Ogston  :  "  Captain  Nolan,  while  riding  in 
advance  of  the  cavalry,  had  his  chest  torn  open  by  a  Russian  shell. 
The  arm  he  was  waving  in  the  air  at  the  moment  remained  high 
uplifted,  and  he  retained  his  seat  on  his  horse,  which  wheeled  around 
and  passed  some  distance  through  the  ranks  before  the  rider  fell." 

The  instantaneous  onset  of  rigor  mortis  has  often  given  decisive 
evidence  of  the  manner  and  circnmstances  of  death.  It  has  at  times 
been  possible,  in  this  way,  to  determine  the  existence  of  fear  or  other 
violent  emotion  at  the  time  of  death.  The  position  of  the  body  has 
often  indicated  that  a  violent  struggle  occurred  before  death,  and  even 
gives  evidence  of  the  exact  nature  of  this  strngtrle,  as  after  death  during 
criminal  assault.  Articles  grasped  in  the  hands  at  the  moment  of  death 
prove  of  extreme  importance  in  deciding  upon  the  circumstances  of  the 
death.  Portions  of  the  hair  and  clothing  of  the  murderer  have  been 
found  in  the  hands  of  the  victim.  Weapons _^/-»(/y  grasped  in  the  hand, 
as  is  possible  only  when  rigidity  supervenes  instantly,  have  indicated 
snicide  or  self-defense,  according  to  the  position  of  the  wea])on  ;  and,  on 
the  other  hand,  weapons  ]nn-])osely  but  loosely  and  awk\vardly  placed 
in  the  hand  of  the  victim  by  the  assailant  liave  correctly  indicated  a 
murderous  assault.  After  poisoning  the  vial  containing  the  drug  has 
been  found  firmly  grasped  in  the  hand  of  the  suicide.      Bodies  recovered 


118  THE    SIGNS    OF    DEATH. 

from  the  water  have  brought  with  them,  clutched  in  the  fingers,  wheels 
and  mud  from  the  bottom,  showing  that  death  occurred  in  the  water 
and  not  on  the  land.  The  position  of  the  body  with  reference  to  the 
surfice  on  which  it  lies  may  be  an  important  consideration.  When 
rigor  mortis  occurs  while  the  body  is  sitting  upright  in  a  chair,  or 
crowded  into  a  confined  space  or  corner,  or  lying  on  rough  ground,  the 
shape  of  the  limbs,  buttocks,  and  trunk  will  be  accurately  apj)lied  to 
the  contiguous  objects.  It  may  thus  be  possible  to  determine  whether 
a  body  has  been  moved  after  rigor  mortis  has  set  in. 

Rigidity  has  been  observed  to  follow  immediately  upon  muscular 
spasm  occurring  in  life,  and  has  been  noted  especially  in  death  from 
tetanus  and  strychnin  poisoning.  Falk^  has  shown  experimentally  that 
tonic  muscular  spasm  in  rabbits  may  be  jJrolonged  for  a  short  time  after 
death  and  be  followed  without  interruption  by  true  rigor  mortis.  The 
theoretic  interest  of  these  experiments  lies  m  the  demonstration  that 
muscular  contraction  of  purely  nervous  origin  may  pass  indistinguish- 
ably  into  postmortem  rigidity,  which  results  from  a  chemical  process 
entirely  independent  of  nervous  influence. 

Practically,  the  question  arises  with  reference  to  the  cases  of  instan- 
taneous rigor  mortis  seen  on  the  battle-field  and  elsewhere,  whether 
tonic  muscular  contraction  does  not  continue  in  these  cases  some  time 
after  death,  while  the  true  rigor  mortis  supervenes,  not  instantly,  but 
after  tlie  lapse  of  some  seconds  or  minutes. 

The  order  in  which  the  muscles  are  aflFeeted  by  rigor  mortis  has  been 
variously  stated  by  the  older  authorities — Nysten,  Larcher,  Casjiar,  and 
Niederkorn.  These  older  conclusions  are  somew^hat  altered  by  Ogston 
and  Tidy,  both  of  whom  give  the  following  order  of  involvement :  The 
eyelids  are  first  affected,  then  the  muscles  of  the  lower  jaw,  followed  by 
the  remaining  flaccid  muscles.  The  lower  limbs  are  next  involved,  but 
both  upper  and  lower  extremities  frequently  become  rigid  simultaneously. 

The  disappearance  of  rigor  mortis  ])roceeds  in  the  order  of  its  onset, 
and  it  may  be  stated  as  a  very  reliable  rule  that  the  earlier  its  onset, 
the  more  rapid  is  its  disappearance.  After  death  from  exhausting  dis- 
eases, in  subjects  of  poor  muscular  development,  rigidity  may,  therefore, 
be  expected  to  appear  promptly  and  disappear  early,  and  may  at  times 
escape  observation.  In  old  age  rigidity  is  usually  well  marked  and 
persistent ;  in  adults  it  is  rather  less  prominent  in  proportion  to  the 
muscular  development ;  but  in  infancy  pronounced-  rigidity  is  observed 
even  after  death  from  asphyxia. 

It  cannot  be  said  that  there  is  any  fixed  period  of  the  usual  continu- 
ance of  rigor  mortis,  and  it  is  only  from  a  study  of  all  the  circumstances 
of  an  individual  case  that  any  opinion  can  be  given  as  to  its  prol)able 
duration.  Taylor  gives  the  usual  period  as  sixteen  to  twenty-four 
hours ;  Ogston,  twenty-four  to  thirty-six  hours ;  Tidy,  twenty-four  to 
thirty-six  hours  in  summer,  thirty-six  to  forty-eight  hours  in  winter. 
Under  fiivorable  circumstances,  as  after  death  by  hanging  or  decapita- 
tion, bodies  have  remained  rigid  until  the  eighth  day.  Kussmaul  states 
1  Berliner  kUnische  Wochenschrift,  1893,  S.  880. 


CADAVEllIC   CUANGES.  119 

that  after  sudden  death  in  muscular  subjects  rigidity  often  persists  for 
two  weeks  or  longer. 

Changes  in  the  Blood  and  Vessels. — Many  of  the  alterations 
found  in  the  blood  at  postmortem  are  the  result  ot"  ])rocesses  occurring 
in  the  last  hours  or  moments  of  life,  and  it  is  often  dillicult  to  dis- 
tinguish all  vital  from  postmortem  blood  changes.  According  to 
Schmidt,  the  eoaguhdhm  of  flic  blood  is  etfectetl  by  the  action  of  a 
fibrin  ferment,  derived  ])rincii»ally  from  the  leukocytes,  ujxm  para- 
globulin,  the  iibrinoplastic  substance  of  the  plasma.  ^\  lien  the  heart's 
action  is  gradually  enfeebled  and  other  conditions  are  favorable,  parietal 
thrombi  frequently  form  in  the  slowly  moving  blood  of  tlie  heart 
chambers.  These  thrombi  are  found  closelv  adherent  to  the  heart-wall 
or  extending  into  adjoining  vessels,  and  on  section  are  found  to  be  com- 
posed of  fibrin  and  leukocytes,  with  a  slight  admixture  of  red  cells. 
They  are  rather  tough  and  elastic,  and  give  evidence  of  having  been  sub- 
jected to  the  heart's  action.  When  the  circulation  has  entirely  ceased,  the 
blood  settles  in  dependent  vessels  exactly  as  it  does  in  the  test-tulH>,  the 
red  cells,  being  of  greater  specific  gravity,  settle  to  the  l)ottoin,  and 
clear,  translucent,  jelly-like  clots  form  in  the  supernatant  fluid,  in 
which  are  suspended  many  leukocytes.  These  true  postmortem  clots 
are  found  in  the  larger  vessels,  and  usually  only  in  the  veins,  in  ^vhi('h 
the  blood  collects  after  death,  and  they  may  be  directly  continuous  with 
the  parietal  thrombi.  The  position  of  the  layers  in  ])()stmortem  clots 
indicates  the  position  that  the  body  has  occupied  at  the  time  of  the 
coagulation  of  the  blood. 

The  extent  of  coagulation  will  depend  on  the  cause  and  manner  of 
death.  According  to  Hoffman,  the  extent  of  coagulation  stands  in 
direct  relation  to  the  length  of  the  death  struii:2:le.  The  fibrin  ferment 
being  principally  derived  from  the  leukocytes,  the  presence  of  Mcll- 
marked  leukocytosis  will  favor  extensive  coagulation.  The  investiga- 
tions of  Corin  ^  indicate  that  the  extent  of  postmortem  coagulation 
depends,  on  the  one  hand,  upon  the  amount  of  fibrinogen  and  fibrin 
ferment  in  the  blood,  and,  on  the  other  hand,  upon  the  action  of  a 
principle,  secreted  by  the  vessel-walls,  which  inhibits  the  action  of  the 
fibrin  ferment.  This  inhibiting  principle  being  abundant  in  the  capil- 
laries, the  blood  in  small  vessels  commonly  remains  fluid  after  death. 

The  wide  variations  observed  in  the  coagulation  of  blood  after  death 
may  be  ])artly  explained  by  a  consideration  of  the  foregoing  factors. 
The  most  extensive  coagulation  is  observed  after  slow  death  from  infec- 
tious fevers  attended  with  marked  leukocytosis.  The  blood  usually 
remains  fluid  after  death  from  asphyxia,  from  burns,  and  in  poisoning 
by  opium,  hydrocyanic  acid,  ])hosphorus,  and  carl)olic  acid.  After 
death  from  diseases  attended  with  anemia  the  blot  clots  feebly  in  ]>ro- 
portion  to  the  severity  of  the  anemia.  When  large  infusions  of  salt 
solution  have  been  used  in  the  treatment  of  acute  hemorrhage,  the  blood 
is  usually  found  entirely  fluid  after  death. 

The  color  of  the  blood  durinfr  the  last  moments  of  life  becomes 
^  Vierteljahresschinft  fur  gerichtliche  Medicin^  v.,  S.  234. 


120  THE    SItJNS    OF    DEATH. 

distinctly  darker,  from  the  reduction  of  oxyhemoglobin  to  hemoglobin, 
a  change  which  is  ordinarily  so  complete  that  it  is  impossible  to  demon- 
strate by  the  spectroscope  any  oxyhemoglobin  in  cadaveric  blood  from 
which  all  air  has  been  excluded  (Hofiman).  Various  exceptions  to 
this  rule  are  seen  in  the  color  of  the  blot>d  after  death  by  some  poisons 
which  have  a  special  action  upon  hemoglobin.  The  blood  is  of  bright- 
red  color  after  death  from  burns,  from  cold,  or  from  poisoning  by  car- 
bonic oxids.  It  is  dark  brown  after  death  from  sulphuric  acids ; 
chocolate  brown  after  poisoning  by  potassium  chlorate ;  and  usually 
dark  brown  in  phosphorus  poisoning. 

Postmortem  hypostases  are  characteristic  signs  of  death  which 
make  their  apj^earance  sometimes  within  an  hour,  frequently  within  six 
hours,  and  usually  within  twelve  hours  after  death,  in  the  form  of  dark- 
red  discolorations  of  the  skin  over  dependent  portions  of  the  body. 
They  are  produced  by  the  distention  with  blood  of  the  capillaries  and 
small  veins  of  the  rete  viucosum,  and  their  size  and  number  depend 
chiefly  upon  the  quantity  of  blood  in  these  small  vessels  at  the  time  of 
death  (Zeigler).  Capillaries  being  microscopic  structures,  the  result  of 
their  distention  is  a  uniform  discoloration  of  the  affected  area.  Hypos- 
tases are  not  formed  where  the  capillaries  have  been  enqitied  by  pres- 
sure of  the  bedding,  and  the  marks  of  clothing  or  constricting  bands  are 
plainly  indicated  by  bloodless  streaks. 

Hypostases  occur  not  only  in  the  skin,  but  may  usually  be  found 
in  the  serous  surfaces  over  dependent  portions  of  the  internal  viscera. 
Over  the  jiosterior  surfaces  of  the  lungs  they  are  almost  invariably 
found,  and  in  this  situation  they  may  make  their  appearance  very  soon 
after  death.  The  cerebral  and  spinal  pia  is  often  markedly  affected. 
The  wall  of  the  gastro-intestinal  tract  is  frequently  discolored  by  post- 
mortem settling  of  blood.  This  may  be  distinguished  from  inflamma- 
tory changes  by  the  absence,  in  the  former  case,  of  the  discoloration  at 
the  points  where  sharp  bends  of  the  canal  have  compressed  the  blood- 
vessels. Discolorations  of  the  serous  surfaces  of  intestinal  viscera  are 
more  often  to  be  referred  to  inflammatory  ecchymoses  than  to  simple 
hypostasis,  and  it  is  manifestly  important  to  avoid  any  confusion  of 
these  conditions. 

Postmortem  lividities  of  an  entirely  different  origin  may  arise, 
usually  at  a  somewhat  later  period,  from  the  difl'usion  of  the  coloring- 
matter  of  the  blood  into  the  tissue  surrounding  tlie  capillaries  and  larger 
vessels.  This  form  of  lividity,  in  an  extreme  degree,  produces  the 
bluish-red  streaks  arising  from  the  diffusion  of  the  blood-pigments  from 
the  larger  veins  of  the  skin,  and  often  marking  out  the  entire  network 
of  a  large  area  of  cutaneous  veins.  The  stains  first  appear  in  isolated 
patches,  which  gradually  enlarge,  coalesce,  and  finally  may  cover  a 
considerable  portion  of  the  skin.  Combinations  of  both  forms  of  lividity 
probably  occur  Avith  considerable  frequence. 

Both  forms  of  postmortem  lividity  are  to  be  distinguished  from  each 
other  and  from  ecchymoses  and  extravasations  of  blood  that  have 
formed  during  life.     The  extravasation  of  blood  usually  produces  an 


CADAVERIC   CHANGES.  121 

elevation  of  the  cuticle,  which  never  occurs  in  simple  postmortem 
lividitv.  On  section,  the  coai2:ulatc(l  or  fluid  blood  of  an  extravasation 
lying  in  the  meshes  of  the  tissue  can,  as  a  rule,  be  ])artly  displaced  bv 
continued  pressure.  When  a  cut  is  made  through  a  simple  hypostasis, 
while  the  blood  in  the  ca])illaries  cannot  be  entirely  dis])laced,  pressure 
will  cause  the  blood  to  exude  from  the  small  veins  in  the  form  of  fine 
black  points — "  puncfa  cruoifa"  The  lividitv  produced  by  diifusion  of 
coloring-matter  is  entirely  unaltered  by  pressure. 

The  extent  of  postmortem  hypostasis  is  frequently  proportionate  to 
the  amount  of  fluid  blood  in  the  cadaver.  It  will  therefore  be  less 
after  death  from  acnte  infectious  diseases,  such  as  pneumonia,  in  which 
a  considerable  volume  of  blood  usually  coagulates  soon  after  death,  and 
greater  after  death  from  such  causes  as  retard  the  coagulation  of  the 
blood.  But  although  hypostatic  mottling  is  certainly  diminished  by 
rapid  coagulation  of  the  blood  in  large  vessels,  it  does  not  appear  that 
the  formation  of  hypostases  depends  exclusively  upon  the  length  of 
time  that  l)lood  remains  fluid.  As  the  blood  in  ca[)illary  vessels 
remains  fluid  (Corin)  and  coagulation  never  involves  the  entire  volume 
of  blood,  there  must  always  remain  in  the  veins  a  considerable  quan- 
tity in  a  condition  capable  of  gravitation  to  the  dependent  capillaries. 
It  is  probable,  therefore,  that  the  activity  of  the  cutaneous  circula- 
tion and  the  quantity  of  blood  in  the  capillaries  at  the  time  of  death., 
as  stated  by  Zeigler,  are  the  more  important  factors  in  the  forma- 
tion of  hypostases.  Further,  the  mottling  of  the  skin  usually  ap[)ears 
some  hours  later  than  the  ordinary  period  of  the  coagulation  of  the 
blood.  Yet  Corin  ^  was  able  to  increase  the  formation  of  postmortem 
lividities  in  rabbits  by  injections  of  peptone,  which  diminishes  the 
coagulation  of  the  blood. 

As  a  positive  sign  of  death  the  value  of  cutaneous  lividity  has  been 
variously  regarded.  There  can  be  no  doubt  that  extensive  discolora- 
tions,  limited  to  dependent  regions,  is  a  positive  and  sometimes  very 
early  proof  of  complete  failure  of  circulation.  According  to  Tidy  and 
Caspar,  postmortem  hypostases  are  invariably  to  be  found  in  some  ])art 
of  the  body,  even  after  death  from  hemorrhage,  a  statement  denied  I)y 
Ogston.  Their  presence  must  be  very  constant  but  hardly  invariable, 
as  indicated  by  the  case  recently  reported  by  Chlumsky,^  in  ^vhi<■h  an 
entire  absence  of  postmortem  lividity  was  observed  in  the  body  of  a 
woman  killed  bv  a  crushine:  blow  on  the  skull  and  numerous  stab 
wounds,  and  thrown  immediately  into  ice-cold  water. 

Extreme  venous  congestion  of  the  skin,  especially  in  circumscribed 
areas,  may  occasionally  simulate  the  real  postmortem  stasis,  but  may  be 
recognized  by  its  distribution  and  complete  displacement  by  pressure. 
The  ecchymoses  produced  bv  frost-bite  are  sometimes  difficult  to  dis- 
tinguish from  postmortem  lividity,  but  the  situation  and  outline  of 
these  lesions  will  usually  serve  as  a  guide.  Bruises  of  the  skin  inflicted 
shortly  before  death  may  be  distinguished  by  the  usual  injury  of  the 

^  Arr/iives  de  Physiolofjie,  1892,  No.  4. 

*  Vierteljahresschrifi/iir  gerichiliche  Mediciti,  x.,  sup.,  S.  22. 


122  THE    SIGNS    OF    DEATH. 

epidermis,  by  the  shape  and  size  of  the  discolored  area,  which  are 
determined  by  the  instrument  used,  and  frequently  by  the  slight  eleva- 
tion of  the  injured  area  due  to  the  effusion  of  blood.  Bruises  inflicted 
a  few  days  before  death  usually  show  inflammatory  reaction,  hyperemia 
about  the  edges,  and  characteristic  changes  of  color  in  the  effused  blood. 
In  many  hemorrhagic  and  infectious  diseases  petechial  spots  or  large 
ecchymoses  appear  in  the  skin,  which  can  seldom  be  mistaken  for  post- 
mortem lividity.  Nor  will  the  cutaneous  ecchymoses  sometimes 
observed  in  hysteria  and  catalepsy  lead  to  any  great  difficulty  in  diag- 
nosis. In  the  last  stages  of  some  diseases  associated  with  extreme 
anemia  death  may  be  forestalled  by  the  appearance  of  a  multitude  of 
superficial  petechise  often  resemblmg  hypostases.  In  cases  of  suffoca- 
tion, especially  by  carbonic  oxid,  discolored  patches  are  sometimes  seen 
on  the  face,  which  may  be  difficult  to  distinguish  from  posttiiortem 
lividity. 

Putrefactive  Changes  in  the  Body. — The  putrefactive  proc- 
esses that  occur  in  the  body  after  death  are  largely  the  result  of 
chemical  processes  initiated  by  and  dependent  upon  the  growth  of 
bacteria.  The  action  of  various  unorganized  ferments  present  in  the 
tissues  has  also  considerable  influence  upon  these  processes,  and  fre- 
quently the  higher  forms  of  animal  life  are  active  agents  in  the  destruc- 
tion of  the  tissues. 

The  very  complex  nature  of  these  processes,  the  natural  difficulties 
in  the  way  of  a  bacteriologic  study  of  the  cadaver,  and  the  compara- 
tive lack  of  practical  value  in  the  solution  of  such  questions  have  pre- 
vented any  exhaustive  studies  in  this  field.  The  gastro-intestinal  tract 
always  contains  a  large  number  of  putrefactive  bacteria,  and  the  bhjod 
and  vessels  serve  as  the  natural  cliannel  for  their  dissemination  through- 
out the  body.  It  has  been  shown  by  numerous  researches  that  some 
pathogenic  and  putrefactive  species,  such  as  bacillus  coli  communis  and 
bacillus  proteus,  may  be  carried  to  the  internal  viscera  even  before 
death,  especially  when  the  fatal  lesion  includes  some  disturbance  of  the 
gastro-intestinal  tract  (Welch,  Neisser).  The  terminal  septicemias  of 
many  chronic  or  acute  diseases  also  leave  the  body  in  a  specially  favor- 
able condition  for  rapid  decomposition. 

Ottolenghi,^  in  a  study  of  the  bacteriology  of  the  blood  of  the 
cadaver,  found  that  forty-eight  hours  after  death,  with  the  body  in  a 
state  of  beginning  decomposition,  the  bacteria  found  in  the  heart's 
blood  were  almost  exclusively  bacillus  mesentericus  vulgatus,  bacillus 
subtilis,  and  micrococcus  albus  liquefaciens.  In  stages  of  more 
advanced  decomposition  in  dogs  and  rabbits  he  found,  in  addition, 
bacillus  candicans,  micrococcus  candicans,  luteus,  and  aurantiacus.  The 
fact  that  in  different  cases  of  sudden  death,  in  a  given  stage  of  decom- 
position, under  definite  conditions  as  to  time  and  temperature,  in  the 
blood  of  one  and  the  same  locality  of  the  human  cadaver,  he  found 
invariably  the  same  micro-organisms,  led  him  to  believe  that  bv  further 
investigations  a  true  chronology  of  decomposition  may  be  established. 
*  Vierteljahresschrift fur  gerichtliche  Medicin,  iv.,  sup.,  S.  9. 


CADAVERIC   CHANGES.  123 

However  desirable  such  a  result  may  be,  it  is  not  probal)le  that  even  a 
complete  knowledge  of  the  bacteriology  of  cadaveric  decompo.-iti(»n 
would  ever  materially  sim[)lify  a  ])rocess  which  is  partially  dependent 
upon  the  action  of  ciiemical  solvents  not  related  to  bacterial  growth, 
and  is  largelv  determined  by  accidental  conditions,  such  as  the  state  of 
the  tissues  at  deatli,  the  temperature  of  the  aii-,  and  the  character  of  the 
surrounding  medium. 

Tlie  bacillus  aerogcnes  capsulatus  lias,  according  to  the  observations 
of  Welch  and  others,  a  very  distinct  intluence  on  the  course  of  putre- 
faction. If  a  rabbit  is  killed  shortly  aiter  the  injection  of  1  c.c,  (16 
minims)  of  a  bouillon  culture  of  this  germ,  the  bacilli  develop  very 
rapidlv  after  death,  with  an  al)nndant  formation  of  gas  in  the  blood- 
vessels and  organs,  especially  the  liver.  At  temperatures  of  18^  to 
20°  C.  (04°-68°  F.)  the  vessels,  organs,  and  serous  cavities  may  be 
full  of  gas  in  eighteen  to  twenty-four  hours,  and  at  temperatures  of 
30°  to  32°  C.  (8G°-90°  F.),  in  four  to  six  hours  when  1  c.c.  (16 
minims)  of  a  bouillon  culture  has  been  injected  into  the  circidation 
shortlv  before  death.  It  has  been  suggested  by  Welch  and  Xiittall 
that  in  some  of  the  cases  in  which  death  has  been  attributed  to  the 
entrance  of  air  into  the  veins  the  gas  found  at  autopsy  may  not  have 
been  atmospheric  air,  but  may  have  been  produced  by  this  or  other 
similar  organisms  (Sternberg). 

It  is  a  noticeal)le  fact  in  experience  with  the  postmortem  changes 
referable  to  this  germ  that  a  large  percentage  of  the  cases  indicate  a 
probable  infection  through  ruptured  l)lood-vessels.  Hemorrhage — from 
wounds,  severe  anemia,  or  postpartum — was  a  chief  or  contributing 
cause  of  death  in  6  of  8  cases  seen  by  the  writer.  From  these 
cases  and  from  the  full  collection  of  reports  reviewed  by  Welch ' 
it  appears  that  an  antemortem  infection  may  often  be  distinguished  from 
the  postmortem  form.  When  the  infection  occurs  before  death,  the 
bacilli  usuallv  reach  the  general  circulation  verv  eai'U-,  and  the  minute 
gas-bubbles  and  colonies  of  germs  are  found  within  a  few  hours  after 
death  in  nearly  all  the  tissues.  When  the  growth  of  the  germ  is 
entirely  postmortem,  their  dissemination  is  slower,  and  the  larger 
vessels  only,  especially  about  the  site  of  the  wound  or  hemorrhage,  are 
found  to  contain  gas.  Even  in  the  latter  case,  however,  the  distribu- 
tion of  the  germs  is  usually  found  to  be  wide-spread  witliin  eight  or  ten 
hours  after  death.  The  gas  produced  is  composed  largely  of  hydrogen 
and  explodes  readily. 

Putrefactive  Discoloration. — Among  the  earliest  signs  of 
decomposition  is  the  appearance  of  a  greenish  discoloration  in  the  skin 
of  the  umbilical  and  hypogastric  or  inguinal  regions  in  bodies  decom- 
posing in  the  air,  and  of  the  midsternal  region  in  bodies  lying  in  the 
water.  This  and  the  later  changes  in  the  color  of  the  skin  are  princi- 
pallv  due  to  the  disinteirration  of  hemoulol)in,  which  is  soon  dissolved 
from  the  red  blood-cells,  diffused  throughout  the  tissues,  and  variously 
altered  by  the  agents  of  decomposition.  It  is  probable  also  that  in 
^Journal  of  Experimental  Medicine,  vol.  i.,  No.  1. 


124  THE    SIGNS    OF    DEATH. 

entirely  bloodless  tissue  a  green  discoloration  may  result  from  the 
decomposition  of  albuminous  matter  (Hoffman,  Schrank). 

Tlie^rs^  greenish  discoloration  is  usually  observed  on  the  third  day, 
but  when  conditions  are  favorable  for  early  putrefaction,  it  may  appear 
before  the  end  of  the  second  day.  Ordinarily  the  greenish  color 
deepens  and  extends  over  the  abdomen,  so  that  by  the  fifth  day  the 
whole  of  the  abdominal  parietes  is  variously  mottled,  and  similar 
patches  are  seen  over  the  genitals,  neck,  back,  and  limbs.  About  this 
time  the  vessels  become  turgid  with  the  fluid  and  gaseous  products  of 
decomposition,  and  the  skin  becomes  tense  and  peculiarly  mottled  in 
appearance.  After  the  first  urek  the  face  is  involved  in  the  greenish 
coloration,  while  the  parts  first  affected  have  gradually  darkened  to  a 
reddish-brown  tint,  with  occasional  patches  of  dark  purple.  After  the 
second  week  the  entire  body  is  uniformly  discolored,  the  more  advanced 
changes  giving  a  dark-brown  or  black  color,  the  less  advanced  stages 
appearing  greenish  or  purple.  At  any  time  during  the  first  week  the 
gases  of  internal  decomposition  may  force  fluid  blood  into  the  superficial 
vessels,  producing  a  difluse  bright-red  color  in  the  skin. 

Putrefactive  Gases. — Some  of  the  most  striking  and  peculiar 
changes  in  the  cadaver  are  caused  by  the  development  of  the  gaseous 
products  of  decomposition  in  the  gastro-intestinal  tract,  serous  cavities, 
blood-vessels,  and  tissue-spaces.  According  to  Tidy,  the  gases  formed 
in  the  stomach  during  life  are  often  inflammable  and  contain  considerable 
pure  hydrogen,  but  very  little  sulj)hureted  hydrogen,  while  postmortem 
decomposition  produces  sulphureted  hydrogen  in  abundance  as  well  as 
carbureted  hydrogen,  which  is  inflammable,  and  ammonia.  After  the 
first  week  of  decomposition  the  offensiveness  of  these  gases  and  the 
quantity  of  sulphureted  hydrogen  and  ammonia  gradually  diminish, 
while  carbureted  hydrogen,  carbonic  oxid,  and  nitrogen  are  relatively 
increased  and  continue  to  be  formed  for  months.  When  decomposition 
begins  in  the  blood,  the  carbonic  dioxid  disappears  and  other  gases  are 
formed  in  this  fluid  (Falk). 

The  first  effect  produced  by  the  development  of  gases  is  the  disten= 
lion  of  the  cavities,  hollow  viscera,  and  tissues  of  the  body.  Cadavers 
at  this  period  are  therefore  considerably  increased  in  size.  The  skin 
becomes  tense  and  elastic,  and  may  crepitate  under  pressure.  The 
natural  folds  and  ungae  are  obliterated,  and  the  features  are  swollen  and 
soon  become  unrecognizable.  The  bodies  of  new-born  infants,  at  this 
time,  have  been  mistaken  for  those  of  children  a  year  old.  Wherever 
the  loose  subcutaneous  tissue  is  abundant,  the  skin  becomes  extremely 
distended,  as  in  the  scrotum,  neck,  groins,  and  axillae.  The  specific 
gravity  of  the  body  is  reduced,  and  cadavers  lying  under  water  usually 
rise  to  the  surface. 

A  second  effect  produced  by  the  development  of  gases  is  the  protru- 
sion of  viscera  or  their  contents.  From  the  fourth  to  the  eighth  day, 
often  earlier,  the  eyes  usually  become  prominent,  or  may  be  forced  well 
out  of  the  orbits.  The  softened  brain  may  be  forced  out  of  the  cranial 
openings  or  along  the  cerebral  openings  or  along  the  cerebral  and  jugular 


CADAVERIC    CHANGES.  125 

veins  (Oi::st(»n),  The  tongue  is  early  distended  by  interstitial  erases 
and  protrudes  more  or  less  from  tiie  mouth,  an  effeet  probably  due  in 
part  to  the  distention  of  the  thorax  and  neck.  Frothy  mucus  is  often 
forced  from  the  bronchi  through  the  nostrils,  a  condition  which  may 
sometimes  be  seen  immediately  after  death  from  edema  of  the  lungs. 
The  fluid  contents  of  the  stomach  may  be  forced  from  the  mouth  or 
mav  settle  in  the  bronchi,  ^vhere  the  ])resence  of  stomach-contents  ordi- 
narily indicates  death  from  inspired  vomitus.  Distention  of  the  intes- 
tines results  in  a  protrusion  of  the  abdomen,  may  force  out  the  contents 
of  the  stomach  or  bladder,  and  may  cause  the  extrusion  through  the 
anus  of  several  inches  of  the  sigmoid  flexure.'  It  is  ])robal)le  that 
gaseous  distention  is  the  cause  of  most  of  the  cases  of  s])ontaneou3 
movement  of  corpses  demonstrated  after  l)m'ial.  The  postm<jrtem  ex- 
pulsion of  the  fetus  is  probably  due  also,  in  the  majority  of  cases,  to  this 
same  cause. 

As  a  common  result  of  changes  in  the  blood,  vessels,  and  tissues  of 
the  body  in  the  earlier  periods,  and  of  gaseous  distention  at  a  later 
stage,  fluid  effusions  of  consideral)le  volume  may  occur  in  the  serous 
cavities  or  in  the  tissues.  Much  of  this  serous  efi^iision  undoubtedly 
belongs  to  the  period  immediately  succeeding  death,  when  the  effusions 
are  usually  of  clear  fluid.  Transudations  of  considerable  volume  are 
not  infrequently  found  at  postmortem  in  cavities  known  to  bo  compara- 
tively free  one  or  two  hours  before  death.  At  other  times  the  effusions 
occur  only  when  decomposition  and  gaseous  distention  are  present,  in 
which  case  the  effusions  are  blood-stained  and  offensive.  The  perito- 
neal, pleural,  and  pericardial  cavities  may  contain  considerable  quanti- 
ties of  this  decomposing  fluid,  which  may  usually  be  distinguished  from 
inflammatory  exudates  by  the  absence  of  pus  and  fibrin.  Collections 
of  blood-stained  fluid  are  often  found  in  these  situations  in  asphyxiated 
infants,  and  when  the  onset  of  decomposition  is  ra]iid  it  may  be  very 
difficult  to  determine  the  true  origin  of  the  fluid.  When  gaseous  dis- 
tention has  become  extreme,  the  fluid  blood  is  forced  into  the  capil- 
laries under  considerable  pressure,  and  the  tendency  toward  transuda- 
tion is  greatly  increased.  The  effect  of  this  displacement  of  the  blood 
in  reddening  the  skin  of  decomposing  cadavers  has  been  mentioned. 
Collections  of  fluid  and  gas  in  the  tissues  are  formed  either  in  the  sub- 
stance of  the  muscles,  where  they  are  produced  in  part  by  the  solvent 
action  of  lactic  acid  and  digestive  ferments,  or  in  the  intermuscular 
septa  or  in  the  subcutaneous  tissues.  Blebs  in  the  skin  are  most  abun- 
dantly ]n'oduced  in  macerated  bodies,  esjjccially  those  of  still-born  infants, 
in  Avhich  the  writer  has  seen  them  extensively  developed  in  twenty-four 
hours.  In  the  solid  viscera  the  production  of  the  gases  and  fluids  of 
decomposition  keeps  pace  with  the  ]n'ocess  in  other  tissues,  being  most 
abundant  in  the  liver  and  kidneys. 

Putrefactive  Changes  in  the  Blood. — Of  ]>ostmortem  changes 
in   the    morphology   of  the   blood   little   is   definitely    known.      At  the 
beginning  of  decomposition,  or,  under  many  conditions,  much  sooner, 
1  Harris,  Hamilton,  Legal  Medicine^  i.,  p.  100. 


126  THE    SIGNS    OF    DEATH. 

the  red  cells  lose  their  hemoglobin,  which  diffuses  through  the  blood- 
vessels, saturates  the  tissues,  and  is  finally  disintegrated,  producing  the 
various  color  changes  noted  iu  the  skin.  Within  a  period  of  two  to 
three  months '  the  blood  loses  its  capacity  to  form  hemin  crystals,  while 
the  final  destination  of  the  iron  contained  in  the  blood-pigment  is  seen 
in  the  black  discoloration  of  the  skin  and  occasionally  of  the  bones  of 
cadavers  exhumed  years  after  burial.  At  the  beginning  of  decomposi- 
tion carbonic  dioxid  disappears  from  the  blood  (Falk).  The  clots  in 
the  blood-vessels  are  early  dissolved.  As  to  the  exact  process  here 
concerned,  Falk  ^  states  that  a  peptonization  of  the  fibrin  cannot  be 
proved,  but  that  the  fibrin  is  first  transformed  into  globulin  and  then 
dissolved  by  a  process  as  yet  undetermined.  After  losing  their  hemo- 
globin, the  red  cells  become  shriveled  and  are  finally  reduced  to  a 
granular  detritus.  They  resist  decomposition  longer  than  the  Avhite 
cells.  At  an  early  stage  of  decomposition  the  nuclei  of  the  leukocytes 
stain  very  faintly,  the  neutrophile  granules  disappear,  and  the  cell-body 
becomes  fragmented  and  disappears. 

Changes  in  the  Viscera. — The  effects  of  decomposition  are 
seen  in  the  changes  in  color  and  consistency,  and  in  the  obliteration  of 
structural  detail  in  the  viscera,,  which  are  also  the  only  means  of  judging 
grossly  of  the  effects  of  vital  inflammatory  changes.  The  separation 
between  postmortem  and  inflammatory  changes  in  the  viscera  not  only 
passes  beyond  the  scope  of  gross  pathology,  but  remains  to-day  one  of 
the  chief  objects  of  microscopic  investigation.  It  is,  therefore,  possible 
in  this  connection  to  give  only  the  barest  outline  of  the  signs  by  which 
may  be  distinguished  the  early  efl'ects  of  visceral  decomposition. 

It  is  commonly  stated  that  putrefactive  softemng  affects  an  entire 
viscus,  while  vital  softening  is  less  general,  a  useful  rule  to  which  there 
is  the  exception  that  acute  degeneration  in  a  viscus,  as  in  acute  yellow 
atrophy  of  the  liver,  usually  produces  a  uniform  diminution  in  the  con- 
sistence of  an  organ  that  is  rather  less  marked  than  the  putrefactive 
change.  Putrefactive  discoloration  of  viscera  is  more  readily  distin- 
guished from  inflammatory  change  by  the  diffuse  nature  of  the  stain  in 
the  one  case,  and  the  irregular  effects  of  arterial  and  venous  hyperemia 
in  the  other.  Purulent  and  fibrinous  exudates  are  never  of  putrefactive 
origin,  l)ut  effusions  of  serum  may  occur  after  death  ;  l)ut  when  the 
latter  result  from  decomposition,  or  any  of  them  are  mixed  with  the 
products  of  decomposition,  they  are  deeply  blood-stained  and  fetid.  The 
obliteration  of  structural  detail  is  effected  very  early  by  decomposition, 
but  is  rarely  so  extensive  when  resulting  from  inflammation  or  vital 
processes.  In  general,  in  distinguishing  lietween  vital  and  putrefactive 
changes,  it  is  essential  to  consider  the  probable  condition  of  the  viscera 
as  determined  by  the  cause  of  death  and  the  circumstances  affecting 
decomposition. 

The  length  of  time  that  the  various  organs  resist  decomposition 
differs  widely,  being  dependent  on  the  density  and  blood  content  of  the 

1   Misuraca,   Vi'rchou-'f<  Jahrrshn-ir/if,  1889,  i.,  8.  488. 

^   VierteljahressdiriftfurgerichtlicheMedicin,  1889,  S.  272. 


CADAVERIC    CHANGES.  127 

tissue,  and  upon  the  ease  \vith  which  they  may  he  reached  hv  tlic  air  or 
penetrated  by  bacteria  or  dissolving  ferments.  The  viscera  wliich  early 
show  the  effects  of  decomposition  arc  the  gastro-intestinal  tract,  the 
liver,   the  spleen,  and  the  brain. 

The  stomach  is  specially  liable  to  suffer  from  postmortem  and  putre- 
factive chauires  on  account  of  its  usual  content  of  fermentinir  food,  diires- 
tive  ferments,  and  bacteria,  and  its  considerable  blood  supj)ly.  It  is  usual 
to  find  the  gastric  mucosa  entirely  unfit  for  microscopic  examination  at 
periods  when  the  other  viscera  are  in  good  preservation.  The  self- 
digestion  of  the  stomach  is  favored  by  the  presence  of  active  digestion 
at  the  time  of  death.  A  few  hours  after  death  the  mucous  membrane 
may  have  a  smooth,  glazed  appearance  from  destruction  of  the  super- 
ficial tubules,  and  from  this  surface  the  blood  may  be  squeezed  out  of 
the  open  vessels.  Complete  perforation  of  the  stomach  may  then  result 
before  any  other  viscera  shows  signs  of  putrefiiction,  as  recorded  by 
\A'ibert  ^  in  a  case  of  triple  perforation  of  the  stomach  and  diaphragm, 
the  pleural  cavity  containing  fluid  food,  ^\■ithout  signs  of  inflammation 
in  the  pleura,  and  without  evidence  of  putrefaction  in  any  other  viscus. 
The  ordinary  process  of  putrefaction  begins  to  affect  the  stomach  usu- 
ally between  the  third  and  the  eighth  day,  but  may  begin  nuich  earlier. 
The  writer  has  seen  the  entire  stomach  of  an  infant  darkly  discolored 
and  much  softened  six  hours  after  birth  and  twcnty-fi)ur  hours  after 
death   in   ufero. 

Beginning  usually  at  the  site  of  postmortem  lividities  and  involving 
the  entire  wall  of  the  stomach,  dark-red  or  green  discolorations  a])pear, 
gradually  enlarge,  most  rapidly  along  the  course  of  the  vessels  of  the 
greater  curvature,  and  coalesce  over  the  whole  surface  of  the  organ, 
which  is  by  this  time  much  softened  or  perforated.  Perforations  and 
areas  of  necrosis  due  to  irritant  poisons  may  usually  be  recognized  for 
considerable  periods,  by  evidences  of  inflammation  and  by  the  location, 
color,  and  depth  of  the  necrotic  tissue.  Some  poisons,  such  as  arsenic, 
may  occasionally  act  as  preservative  agents  on  the  stomach,  in  which 
case  the  original  condition  of  the  organ  may  be  determined  three  or-  four 
weeks  after  death.  It  is  important  to  remember  that  the  stomach 
shortlv  after  death  mav  l)e  found  intenselv  reddened  from  arterial 
hyperemia,  or  darkly  discolf)red  from  venous  congestion,  or  variously 
stained  l)y  bile,  or  its  wall  doul^led  in  thickness  from  edema. 

The  intestines  are  changed  by  decomposition  in  much  the  same  way 
as  the  stomach,  l)ut  less  rapidly,  and  they  are  much  less  subject  to  self- 
digestion.  The  esopliagus  is  a  very  resistant  structure,  recognizable  after 
the  stomach  and  intestines  have  become  disintegrated.  The  mesentery, 
also,  frequently  j)ersists  after  the  intestines  have  been  destroyetl. 

The  Liver. — The  first  effects  of  decomposition  apjiear  so  early  in 
this  viscus  that  the  reduced  consistence  of  the  flal)l)y  "summer  liver" 
is  the  usual  condition  of  the  organ  found  during  warm  weather,  at 
autopsies  conducted  from  twelve  to  twenty-four  hours  after  death.  Of 
the  internal  organs,  the  liver  is  usually  the  first  to  develop  the  gases  of 

^  Annates  de  Hygiene,  1801,  p.  82. 


128  THE    SIGNS    OF    DEATH. 

decomposition,  which  may  render  it  emphysematous  at  the  end  of  thirty- 
six  hours,  or  much  earlier  when  the  baciUus  aerogenes  capsulatus  is 
multiplying  abundantly.  Later,  the  usual  greenish  discoloration  appears 
on  the  convex  surface,  gradually  deepens  and  extends  until  the  organ 
becomes  uniformly  black.  One  to  two  months  or  more  are  usually 
required  to  reduce  this  viscus  to  a  puify,  structureless  mass.  The  gall= 
bladder  is  rather  more  resistant  than  the  liver,  but  bile-pigments  may 
early  and  extensively  diffuse  through  the  adjacent  tissue.  The  spleen, 
when  swollen  and  hyperemic  at  death,  decomposes  rapidly,  but  when 
firm  and  comparatively  bloodless,  may  long  resist  putrefaction. 

The  brain  begins  to  decompose  in  the  basal  ganglia  and  dependent 
portions,  where  fluids  naturally  gravitate,  and  in  the  course  of  two  or 
three  weeks  usually  becomes  nearly  diffluent.  Structural  details  have, 
however,  been  recognized  after  some  months.  In  infants  the  brain  very 
rapidly  becomes  softened,  owing  to  its  original  soft  condition,  the  readier 
access  of  air,  and  the  frequency  of  effusions  of  blood  and  serum  into  the 
pia.  It  may  be  difficult  to  distinguish  the  "  hortensia  reddening  "  of 
acute  encephalitis  (Virchow)  from  postmortem  discoloration. 

The  trachea  and  larynx  are  the  first  internal  structures  to  show  the 
discoloration  resulting  from  putrefaction.  In  from  three  to  eight  days 
the  nuicous  membrane  of  the  larynx  and  adjoining  portion  of  the 
trachea  are  found  of  a  reddish-brown  or  dark-green  color. 

The  remaining  viscera  are  less  easily  changed  by  decomposition. 

The  heart  and  large  blood=vessels,  in  the  absence  of  extensive 
pathologic  changes,  prove  very  resistant  structures,  and  lesions,  such  as 
pericarditis,  have  been  demonstrated  at  a  period  when  other  organs 
were  far  advanced  in  decomposition. 

The  lungs  are  usually  partially  preserved,  and  pathologic  lesions 
are  demonstrable  in  them,  longer  than  with  more  cellular  viscera,  but 
the  period  of  their  preservation  varies  greatly.  Tidy  refers  to  two 
cases  in  which  the  lungs  of  children,  after  seven  months'  burial  in  a 
dry  soil,  jvere  more  decomposed  than  any  other  viscera,  some  of  which 
may  have  been  preserved  by  the  presence  of  arsenic.  In  bodies  sub- 
merged in  water,  at  the  end  of  the  first  month  the  lungs  are  usually 
very  emphysematous  and  completely  overlie  the  heart.  Isolated  bullse 
appear  in  the  pleura  as  decomposition  begins.  After  three  and  a  half 
mouths  the  lungs  are  collapsed  and  the  pleural  cavities  contain  reddish 
serum  (Devergie).  The  diaphragm  is  usually  distinguishable  after  six 
months. 

The  kidney,  if  normal  or  sclerosed,  resists  decomposition  longer  than 
the  liver,  but  if  acutely  inflamed  at  death,  its  structural  details  are 
obliterated  very  rapidly. 

The  bladder,  if  contracted  and  empty,  is  one  of  the  most  resistant 
structures,  but  decomposes  rapidly  if  it  has  been  distended  and  inflamed. 
Some  importance  attaches  to  the  fiict  that  in  the  early  stages  of  decom- 
position of  its  mucous  membrane  there  is  usually  an  albuminous  exudate 
into  the  urine,  ])ro(lucing  a  postmortem  albuminuria,  demonstrable  in 
most  cases  within  forty-eight  hours  after  death. 


CADAVERIC    CHANCES.  129 

The  uterus  has  repeatedly  been  found  in  a  state  of  fair  preservation 
when  all  other  viscera  were  indistin^uishahle.  Its  persistence  is  ratlier 
less  uniform  in  children,  but  in  adults  not  only  the  sex  of  the  body,  but 
the  question  of  a  recent  pregnancy,  has  been  determined  after  long 
periods,  when  the  skull  and  long  bones  were  extensively  bared  and  the 
ligaments  separating. 

Conditions  Influencing  Putrefaction. — Temperature. — Ijac- 
terial  growth  and  putrefactive  processes  are  arrested  by  temperatures 
approaching  the  freezing-point  or  considerably  below  the  boiling-point. 
The  most  favorable  temperature  is  between  70°  and  100°  F.,  and  varia- 
tions above  or  below  these  limits  very  promptly  affect  the  progress  of 
decomjiosition  in  the  recently  dead  body. 

Moisture. — Complete  dryness  arrests  bacterial  growth,  while  putre- 
factive species  are  most  active  in  very  fluid  media,  it  has  been  shown 
that  the  denser  a  viscus,  the  less  rapid  is  its  decomposition.  Edematous 
or  inflamed  tissues  putrefy  early.  Bodies  that  have  lain  in  water  and 
are  subsequently  exposed  to  the  air  decompose  with  extreme  rapiditv, 
although  continued  submersion,  by  the  exclusion  of  air,  delays  putre- 
faction. Ordinarily,  the  tissues  contain  sufficient  moisture  for  raj)id 
decomposition,  but  it  has  been  shown  l)y  Dupont^  that  bodies  exposed 
to  the  air  lose  moisture  and  weight  at  the  rate  of  7.7  grams  (120  grains) 
per  kilo  each  day.  With  other  conditions  unfavorable  for  putrefaction 
the  body  may  become  so  desiccated  that  decomposition  ceases.  In- 
stances of  decomposition  thus  arrested  are  seen  in  the  long  preservation 
of  the  bo<lie3  of  travelers  in  the  Sahara  desert.  The  excessive  heat  of 
the  sun,  aided  by  a  very  dry  atmosphere,  has  here  a  distinct  preservative 
influence.  It  will  generally  be  f nmd  that  moisture  is  more  imjmrtant 
for  decomposition  than  either  heat  or  air,  and  that  slight  variations 
in  this  factor  have  a  controlling  effect  on  the  rapidity  of  putrefactive 
processes.  It  has  often  been  observed  that  moist  air,  even  if  cold,  is 
more  favorable  to  decomposition  than  a  warm  but  dry  atmosphere. 

The  access  of  air  }>romotes  ])utrefaction  by  carrying  moisture,  l)ac- 
teria,  and  oxygen  to  the  cadaver.  Of  all  gases,  decomposition  proceeds 
most  rapidly  in  oxygen,  especially  when  it  is  mixed  with  nitrogen,  as  in 
the  air,  and  the  comparative  absence  of  oxygen  greatly  retards  decom- 
position. For  this  reason  deep  burial  in  the  earth  or  water,  the  use  of 
leaden  coffins,  or  saturation  of  the  air  with  turpentine,  which  absorbs 
oxygen,  insures  a  temporary  preservation  of  the  body.  INIoist,  hot,  and 
stagnant  air  is  the  most  favorable  medium  for  decomposition. 

Time  and  Place  of  Interment. — Bodies  lying  in  the  air  for  some 
time  not  only  suflcr  from  the  action  of  oxygen,  but  attract  the  micro- 
organisms and  insects  of  the  air,  so  that  decomjiosition  is  hastened  and 
its  character  permanently  established.  Ortila  states  that  in  stmnner  a 
body  exposed  for  five  or  six  days  before  burial  undergoes  in  a  month  as 
much  change  as  it  would  have  suffered  at  the  end  of  seven  months  had 
it  been  interred  at  onc'e.  Burial  in  a  shallow  grave,  without  clothing 
or  coffin,  does  not  exclude  oxygen  or  the  bacteria  of  the  soil,  and  decom- 
1  Vi)-chow's  Jahresbericht,  1891,  i.,  S.  510. 
Vol.  L— 9 


130  THE    SIGNS    OF    DEATH. 

position  is  therefore  rapid.  The  most  favorable  soil  for  decomposition 
is  a  moist,  porous  loam,  moldy  or  impregnated  with  animal  or  vegetable 
matter.  The  occurrence  of  adipocere,  however,  is  favored  by  these  con- 
ditions, the  formation  of  which  completely  transforms  the  usual  course 
of  putrefaction.  The  most  favorable  soil  for  the  preservation  of  the 
body  is  sand,  gravel,  or  clay,  in  which  moisture  is  deficient  and  the 
desiccation  of  the  body  rapid.  In  such  a  soil,  in  a  deep  grave,  and 
in  a  hermetically  sealed  leaden  coffin,  the  body  may  long  remain 
in  remarkably  good  preservation.  Reinhard  ^  examined  many  bodies 
exhumed  in  Saxony,  and  found  that  in  sand  or  gravel  the  destruction 
of  the  soft  parts,  in  children,  was  complete  in  four  years  ;  in  adults,  in 
seven  years.  In  clay  the  process  was  somewhat  slower.  Most  remark- 
able is  the  preservation  of  bodies  buried  in  peat-bogs,  from  which 
cadavers  have  been  recovered  in  an  excellent  state  of  preservation  after 
the  lapse  of  a  century.^ 

Age  and  Sex. — Under  similar  conditions  the  bodies  of  children  de- 
compose more  rapidly  than  tho§e  of  adults.  Corpulent  bodies  decom- 
pose more  rapidly  than  the  lean  and  emaciated.  There  is  no  evidence 
to  show  that  the  process  of  decomposition  does  not  proceed  with  equal 
rapidity  in  both  males  and  females  ;  any  difference  that  might  be  noted 
depending  upon  accidental  circumstances  and  not  upon  the  sex.  The 
female  body  usually  containing  more  adipose  tissue,  is  more  readily 
converted  into  adipocere. 

The  cause  of  death  and  the  condition  of  the  body  at  death  have 
a  very  prominent  influence  upon  the  course  of  decomposition.  Some 
of  the  factors  here  concerned  have  already  been  mentioned.  Any  dis- 
ease which  leaves  the  tissues  inflamed,  edematous,  degenerated,  or, 
as  is  often  the  case,  infected  with  bacteria,  will  be  followed  by  rapid 
decomposition.  Such  are  the  acute  infectious  diseases  and  chronic  dis- 
ease terminating  in  dropsy  or  septicemia.  The  most  rapid  progress  of 
decom])osition  in  the  writer's  experience  was  noted  in  the  body  of  a 
woman  dying  from  postpartum  hemorrhage  after  treatment  by  large  in- 
fusions of  salt  solution.  When  sudden  death  occurs  in  the  absence  of 
fever,  infection,  or  edema,  and  when  chronic  diseases  terminate  with 
emaciation  and  anemia,  the  conditions  are  less  favorable  for  bacterial 
growth,  and  putrefaction  is  less  rapid.  The  presence  of  certain  poisons 
in  the  body  which  act  as  antiseptics  may  interfere  with  bacterial  growth 
and  retard  putrefactive  changes.  Instances  of  this  sort  have  been  seen 
after  death  from  arsenic,  antimony,  clilorid  of  zinc,  phosphorus,  and 
some  other  mineral  poisons,  and,  according  to  Devergie,  after  poisoning 
by  chloroform,  strvchnin,  and  carl^onic  oxid. 

Cadaveric  Changes  in  Bodies  ^Embalmed. — The  progress 
of  postmortem  decomposition  may  be  arrested  permanently  by  the  in- 
travenous injection  of  the  embalming  fluids  used  by  undertakers. 
When  the  fluids  are  injected  very  soon  after  death,  as  usually  occurs, 
decomposition  may  be  entirely  prevented  and  tlie  tissues  may  be  found 
in  excellent  preservation  for  months,  and  proljably  years,  after  burial. 
1  British  Medical  Journal,  1883,  p.  267.  *  Lancet,  1873,  p.  817. 


CADAVERIC   CHANGES.  131 

The  arrest  of  decomposition  does  not,  however,  interfere  with  the  effects 
of  (lesifcatioii,  a  process  which  may  k'ad,  after  tlic  lapse  of  years,  to  the 
complete  mummilication  of  the  corpse.  \\  hen  the  work  of  the  embalmer 
has  been  thoroughly  done,  one  may  expect  to  find  that  the  only  changes 
in  the  internal  viscera  of  the  embalmed  and  })roperly  buried  corpse  are 
those  of  de-siccatioit,  while  the  degree  of  these  changes  will  depend  upon 
the  period  that  has  elapsed  since  death  and  the  character  of  the  sur- 
rounding soil.  The  ravages  of  insects  and  bacteria  under  these  circum- 
stances appear  to  be  confined  to  the  skin,  the  eyes,  and  the  more  acces- 
sible mucous  membranes. 

The  followino;  abstract  from  the  notes  of  a  case  in  which  the  autopsy  was 
performed  six  months  after  deatli  will  serve  for  illustration.  Tlie  body  of  a  cliild 
five  years  of  age  had  been  embalmed  by  the  intravenous  injection  of  preserving 
fluids,  and  buried  in  a  dry  gravel,  in  a  wooden  casket,  surrounded  by  a  casing- 
box  of  pine.  The  outer  box  was  fcnuid  quite  dry,  the  casket  was  moist,  but  no 
molds  were  seen  inside  or  out.  Running  from  the  foot  of  the  casket  was  a  blood- 
stained line  which  had  soiled  the  coverings  of  the  casket  and  the  bottom  of  the 
box.  The  internal  coverings  were  moist,  the  clothing  of  the  cadaver  much 
decayed,  especially  over  and  tinder  the  trunk. 

Covering  the  clothing  and  the  skin  of  the  entire  l>ody  was  a  thic-k  layer  of 
brownish  dust  in  which  were  many  small  white  insects,  the  size  of  a  pinhead, 
and  their  small  oval  eggs.  This  dust,  composed  of  the  insect  excreta,  had  pro- 
duced a  brownish  discoloration  of  the  skin,  especially  of  the  face,  which  was 
nearly  black. 

The  body  ivas  rigid,  the  skin  mucli  desiccated,  and  over  the  fingers  almost 
hornified.  Nails  and  hair  were  firm.  Teeth  very  loose.  The  orbits  contained 
only  a  little  black  semifluid  matter,  but  the  lids  and  lashes  were  intact.  The 
cheeks,  chin,  nose,  and  features  were  apparently  natural  and  not  shrunken. 

Internal  Examination. — The  tissues  of  the  neck  were  moister  than  else- 
where, and  on  the  right  side  the  tissues  were  evidently  edematous.  The  lym])h- 
nodes  in  both  sides  of  the  neck  were  much  swollen.  The  tissues  of  the  posterior 
pharyngeal  wall  were  very  dark,  but  not  necrotic,  and  at  one  point  a  small 
ragged  opening  was  noticed.  Behind  the  right  tonsil  was  a  large  ragged  cavity, 
partly  empty,  but  containing  in  its  deepest  portions  some  bright  red  clotted  and 
fluid  blood.  In  the  internal  carotid  artery  was  found  an  irregular  opening  com- 
municating freely  with  the  above  cavity,  the  cause  of  death  having  been  hemor- 
rhage from  this  vessel. 

The  tonsils  showed  numerous  deep  excavations  from  a  previous  croupous 
inflammation,  but  no  ulceration  or  necrosis.  The  mucous  memljrane  of  the  nares 
was  in  an  advanced  stage  of  decomposition,  the  periosteum  was  loose,  and  the 
vomer  free  from  its  articulations.  The  lungs  were  very  firm,  the  pleura  desic- 
cated and  shiny.  In  the  pleural  cavities  were  four  ounces  of  yellowish,  trans- 
parent fluid.  Niunerous  lobules  were  sharply  marked  off  by  their  dark-red  color, 
due  to  inspired  blood.  Heart. — Hard,  tightly  contracted.  Right  side  con- 
tained a  dark  clot;  left  side  entirely  empty.  Liver. — Much  desiccated  super- 
ficially and  very  firm;  color  light  leaden;  jnarkings  indistinguishable.  Gall- 
bladder was  contracted,  empty.  Spleen. — ^Moderately  enlarged,  capsule  smooth, 
iiard,  and  dry;  section  dark  gray;  Malpighian  bodies  light  gray  and  distinct. 
Kidneys  were  very  firm,  dry;  markings  regular  and  distinct.  Esophagus  was 
contracted  and  extremely  hard.  Stomach  was  tightly  contracted,  firm,  mucous 
membrane  perfectly  preserved  and  thrown  into  prominent  rnga^;  contents  a  little 
semifluid  brownish  matter.  Intestines. — Periosteum  shiny,  dry,  ligiU-colored, 
like  ])aper,  mucous  membrane  intact.  The  large  arteries  were  hard,  dry, 
shrunken;  the  veins,  firm,  containing  a  little  clotted  blood,  in  places  decol- 
orized and  gelatinous. 

Microscopic  examination  showed  all  the  tissues  examined,  except  .some  of 
the  swollen  cervical  nodes  and  the  hepatic  cells,  to  be  very  well  preserved. 
Colonies  of  cocci  were  demonstrated  in  the  wall  of  the  abscess. 


132  THE    SIGNS    OF    DEATH. 

From  this  case  it  appears  that  'wherever  the  preserving  fluid  was 
carried  by  the  blood-vessels  decomposition  was  completely  arrested. 
The  single  exception  was  the  liver,  M'hile  the  destruction  of  the  eyes 
may  be  referred  to  the  imperfect  access  of  fluid  to  these  organs.  The 
ravages  of  tlie  insects  were  entirel}'  superficial  to  the  epidermis,  a  fact 
which  suggests  that  if  the  skin  had  been  treated  with  some  irritant 
antiseptic,  such  as  corrosive  sublimate,  the  discoloration  resulting  from 
the  excreta  of  the  insects  might  have  been  avoided.  The  insects 
belonged  to  tlie  species  Tyrogliphus,  and  promptly^  perished  upon 
exposure  to  dry  air. 

Unfortunately,  the  methods  of  embalming  used  by  undertakers  are 
by  no  means  uniform.  The  variety  of  preserving  fluids  on  the  market 
is  considerable,  and  their  action  is  not  always  reliable.  In  many  local- 
ities the  operator  is  content  to  inject  a  little  of  the  fluid  into  the 
serous  cavities  instead  of  into  the  blood-vessels,  in  which  case  it  is 
impossible  for  any  of  the  viscera  to  become  thoroughly  impregnated, 
while  the  muscular  and  nervous  systems  remain  entirely  unaflected.  It 
is  not  to  be  supposed,  therefore,  that  in  every  case  in  which  the  body  is 
said  to  have  been  embalmed  the  state  of  jn-eservation  will  be  found  as 
perfect  as  in  the  case  descril)ed. 

The  Course  of  Putrefaction  in  Water. — The  process  of 
decomposition  in  water  is  more  uniform  than  in  air,  but  is  subject  to 
wide  variations.  Submersion  m  shallow,  warm,  and  stagnant  fresh 
water  retards  putrefaction  little  or  not  at  all,  while  after  deep  submer- 
sion in  cold  salt  water  bodies  have  been  ftumd  Avell  preserved  after 
many  years.  Hoenig^  reports  the  recovery  of  several  Mell-preserved 
bodies  that  had  been  thrown  into  a  salt  well  after  the  battle  of  Salzburg, 
forty-one  years  before.  About  the  fourteenth  day,  or  earlier  in  summer, 
and  after  six  weeks  in  winter,  the  development  of  gas  usually  brings 
the  body  to  the  surface,  where  it  decomposes  more  rapidly.  It  may 
then  sink  and  rise  a  second  or  a  third  time,  as  determmed  by  the 
volume  of  confined  gases. 

The  observations  of  Devergie  at  the  Paris  morgue  on  the  course  of 
putrefaction  in  submerged  bodies  are  widely  quoted,  and  are  claimed  by 
this  investigator  to  offer  reliable  data  from  which  to  calculate  the  length 
of  time  that  bodies  have  remained  in  the  water.  The  following 
descriptions  a])ply  to  bodies  submerged  during  cold  weather  and  in 
fresh  Avater.  In  warm  weather  the  course  of  decomposition  was  found 
to  be  more  irregular  and  very  much  more  rapid. 

During  the  first  four  or  five  days  rigidity  may  persist.  The  skin  of  the 
tips  and  sides  of  the  lingers  is  whitened. 

At  the  end  of  one  week  rigor  mortis  is  absent,  the  palms  of  the  hands  and 
soles  of  the  feet  are  whitened.  The  skin  of  the  face  is  softened  and  slightly 
bleached. 

From  the  seventh  to  the  twelfth  day  the  backs  of  the  hands  and  the  face  are 
bleached. 

At  the  end  of  two  weeks  the  face  is  swollen  and  shows  a  few  red  spots. 
There  is  a  greenish  discoloration  over  the  midsternal  region.  Except  on  the 
dorsum  of  the  feet  the  skin  of  both  hands  and  feet  is  white  and  .slightly  wrinkled. 

1  Berliner  klinische  Wochenschrift,  1890,  p.  1212. 


CADAVERIC    CHANGES.  133 

One  month:  Tlie  face  is  swollen  and  reddish  brown  in  color;  the  eyelids, 
lips,  and  mck  are  green.  The  front  of  the  chest  |>rescnls  a  s|)ot  six  inches  in 
diameter,  brown  in  the  center  and  greenish  at  the  edges.  The  skin  is  much 
wrinkled.  The  scrotum  and  penis  are  distended  by  gas.  The  lungs  are  very 
emphysematous. 

Two  months:  The  face  is  extremely  swollen  and  brown.  The  skin  of  the 
abdomen  and  limbs  remains  natural ;  elsewhere  it  is  variously  discolored  and 
often  detached.  The  nails  and  hair  may  easily  be  detached.  The  veins  are 
empty  of  blood  and  filled  with  gas.  The  right  ventricle,  if  previously  gorged  with 
blood,  is  of  jet-bhifk  color. 

Two  and  one=half  months :  The  skin  is  everywhere  discolored,  and  with 
the  hair  and  tinger-nails  comj)letely  detached.  The  abdomen  is  much  distended. 
The  cheeks,  chin,  axilhe,  breasts,  and  inner  parts  of  the  thighs  may  be  partly 
converted  into  adipocere. 

Three  and  one=half  months  :  The  features  are  largely  destroyed,  and  recog- 
nition is  impossible.  The  skin  of  the  hands  and  feet  and  in  many  other  .spots 
has  disappeared.  The  lungs  have  collapsed,  and  the  ])leural  cavities  contain 
reddish  fluid.     The  face,  upper  part  of  neck,  and  axilke  may  be  partly  saponified. 

Four  and  one=half  months :  The  skull  is  bare,  and  the  skin  of  the  face, 
neck,  iiud  inner  parts  of  thighs  is  destroyed  or  saponified  and  incrusted  with  cal- 
careous salts.     The  anterior  ])ortions  of  the  brain  may  show  traces  of  adipocere. 

After  four  and  one=half  months  it  becomes  impossible  to  follow  accurately 
the  stages  of  iK'eom}iosition. 

Calculation  of  the  Time  of  Death  from  the  State  of  the 
Cadaver. — It  will  readily  be  seen  from  the  great  variety  of  conditiou.s 
thus  far  detailed  as  markedly  aifeeting  the  rate  of  putrefactive  changes 
that  the  difficulties  in  the  way  of  determuiing  the  time  of  d(>atli  from 
the  examination  of  the  dead  body  are  always  very  great  and  often  in- 
surmountable. Even  during  the  tirst  few  hours  after  deatli  a  consid- 
eration of  the  internal  temjierature,  which  is  the  most  reliable  guide, 
gives  very  imperfect  data.  At  later  periods  the  stage  of  decomposition 
in  ^\  hich  the  body  is  found  is  much  less  definite  evidence  of  the  time 
that  has  elapsed  since  death.  The  greatest  reliance  may  l)e  placed,  as 
claimed  by  Devergie,  on  the  uniformity  of  putrefactive  changes  in  bodies 
immersed  in  cold  water.  Under  other  conditions,  while  decomposition 
in  the  majority  of  cases  follows  the  chronologic  order  of  Caspar,  given 
elscAvhere,  entirely  contradictory  results  are  frequent.  Nearly  all  ob- 
servers are  therefore  agreed  that  it  is  usually  impossil^le  and  unwise 
to  attempt  to  calculate,  even  within  wide  limits,  the  time  of  deatli 
from  the  stage  of  decomposition  in  the  cadaver. 

The  following  reports  will  serve  to  emphasize  tlie  wi.-dom  of  this 
conclusion.  Caspar  once  examined  the  bodies  of  14  soldiers,  of  the 
same  ag-e,  liviup;  under  the  same  conditions,  dving  at  tiie  same  time  bv 
ffunshot  wounds  durinsr  the  cold  weatlier  of  ^larch,  and  Iviuir  in  the 
same  dead-house  for  two  days,  and  yet  in  no  2  cases  did  lie  find  similar 
signs  of  putrefaction.  The  same  author  refers  to  the  instance  of  an  old 
couple,  between  fifty  and  sixty  years  of  age,  whose  bodies  were  dis- 
covered, four  days  after  death  from  carbonic  oxid  poisoning,  in  the  month 
of  November.  In  the  body  of  the  man,  who  was  thin,  the  skiy  of  the 
abdomen  and  back  w^as  green,  and  the  mucous  membrane  of  the  trachea 
was  brownish  red  and  fetid,  wdiile  the  body  of  the  woman,  who  was 
very  fat,  showed  no  traces  of  decomposition.  Tidy  has  collected 
numerous  cases  showmg  that  advanced  putrefaction  may  be  found  as 


134  THE    SIGNS    OF    DEATH. 

early  as  eight  hours  after  death,  or  its  onset  may  be  delayed  several 
days.  His  cases  show  equally  well  that  the  soft  parts  may  be  destroyed 
within  a  year,  or  remain  well  preserved  for  many  years. 

There  remains,  however,  a  large  class  of  cases  in  which  the  course 
of  putrefactive  changes  is  more  gradual  and  uniform.  From  prolonged 
observations  on  bodies  exposed  to  the  air  or  buried  in  the  ordinary 
manner,  conditions  in  which  he  believes  decomposition  to  proceed  with 
about  equal  rapidity,  Caspar  has  prepared  the  following  series  of 
descriptions,  by  which  may  be  drawn  inferences  as  to  the  time  of  death  : 

One  to  three  days :  A  greenish  discoloration  appears  in  the  skin  at  the 
center  of  the  abdomen.     The  eyeballs  are  distinctly  softened. 

Three  to  five  days :  The  greenish  discoloration  of  the  abdomen  has  deep- 
ened and  extended  to  other  parts  of  the  body,  spreading  in  the  following  order : 
groins,  genitals,  breast,  face,  neck,  upper  and  lower  limbs. 

Eight  to  ten  days  :  The  superficial  discoloration  has  become  more  intense, 
and  in  the  areas  first  affected  there  may  be  a  slight  reddish  or  brownish  tinge. 
The  blood-pigment  has  extensively  diftused  through  the  walls  of  the  cutaneous 
veins,  plainly  outlining  their  course  in  dark-red  streaks,  which  later  coalesce, 
producing  a  peculiar  marbled  appearance.  Gaseous  decomposition  has  begun  in 
the  tissues,  viscera,  and  cavities,  and  the  abdomen  is  distended,  the  face  swollen, 
and  the  skin  everywhere  puffy.  The  cornea  has  sunken  and  is  concave.  The 
sphincter  ani  is  relaxed. 

Two  to  three  weeks:  The  skin  is  everywhere  discolored  with  green,  brown, 
or  black  patches.  The  epidermis  is  detached  in  places  or  is  raised  into  blebs, 
filled  with  reddish  fluid.  The  hair  and  nails  are  readily  separated.  The  body  is 
uniformly  swollen  from  gaseous  distention.  The  eyelids,  lips,  nose,  and  cheeks 
are  so  swollen  and  discolored  that  the  features  are  unrecognizable. 

Four  to  six  months :  The  decomposed  walls  of  thorax  and  abdomen  are 
ruptured,  and  the  viscera  are  partially  extruded  or  exposed.  The  sutures  of  the 
skull  are  loosened.  The  ligamentous  attachments  are  loosened,  and  the  long 
bones  separate  at  the  joints.  The  viscera  are  reduced  to  ill-defined  pulpy 
masses. 

At  more  advanced  ])eriods  the  stages  of  decomposition  hardly  admit  even  of 
this  general  description. 

During  the  second  year  the  soft  tissues  of  the  body  usually  become  dry, 
shrunken,  and  brown  or  black.  At  almost  any  period  after  a  few  months,  most 
frequently  after  the  first  year,  hard  white  crystalline  deposits  of  phosphate  of 
lime  may  be  found  on  the  mucous  membrane  of  the  stomach  or  on  the  surfaces 
of  other  soft  viscera.  Under  favorable  circumstances  nearly  the  whole  body  may 
be  saponified. 

After  four  years  it  is  seldom  possible  to  distinguish  the  separate  viscera. 
After  seven  to  ten  years  the  soft  parts  have  usually  disappeared.  Finally,  the 
long  bones  only  may  remain,  the  short  and  flat  bones,  the  base  of  the  skull,  and 
vertebrae  having  crumbled  into  powder.  The  bones  of  bodies  buried  in  peat-bogs 
have  been  found  to  be  entirely  dissolved,  while  the  soft  parts  remained  in  a  good 
state  of  preservation.  The  hair,  bones,  and  especially  the  teeth  are  the  most 
nearly  indestructible  portions  of  the  body. 

The  ^Entomology  of  the  Cadaver. — During  the  past  decade 
and  earlier  there  have  been  recorded  a  considerable  number  of  observa- 
tions on  the  fauna  of  graves,  and  the  facts  elicited  have  given  increased 
interest  and  importance  to  the  sttidy  of  the  higher  forms  of  animal  life 
supported  by  the  cadaver. 

Among  the  earliest  forms  of  animal  life  to  be  found  upon  the  unpro- 
tected dead  bodv  must  be  reckoned  the  maffffots  which  sometimes  make 
their  appearance  a  few  hours  after  death.     The  summer  season  and  the 


CADAVERIC   CHANGES.  •  135 

presence  of  external  wounds  improperly  cared  for  are  usually  the  only 
necessary  conditions  for  their  tirowth.  The  fact  that  these  and  other 
forms  derived  from  the  aii-  are  more  abundantly  found  upon  bodies 
exposed  to  the  air  has  sometimes  led  to  the  conclusion  that  bodies  in 
which  the  evidences  of  their  ravaues  were  distinctly  apparent  vears 
alterward  had  decomposed  in  the  air  for  some  time  before  interment  in 
the  earth.  Yovanovitcli  ^  gives  a  review  of  the  existing  literature  and 
a  description  of  2  original  cases,  and  concludes  tiiat  the  study  of  the 
entomology  of  the  cadaver  can,  with  comparative  })recision,  determine 
the  time  that  the  body  has  been  dead,  the  season  of  the  year  when 
death  occurred,  whether  the  body  up  to  the  time  of  its  discovery  had 
remained  in  the  same  locality,  whether  the  individual  had  died  in  the 
city  and  was  buried  in  the  country,  or  vice  versa,  and  many  other  cir- 
cumstances attending  the  death. 

INIegnin,^  in  one  of  his  recent  studies,  explains  many  of  the  con<litions 
affecting  the  growth  of  insects  in  the  cadaver.  According  to  his  obser- 
vations, the  inroads  of  insects  occur  in  a  regular  sequence,  according  as 
the  body  by  its  odor  attracts  the  various  forms  or  furnishes  a  suitable 
pabulum  for  their  existence.  Before  decomposition  has  fairly  begun 
the  cadaver  attracts  certain  fties  of  the  species  Curtonevra  and  Calli- 
phora.  After  three  or  four  days,  when  the  odor  of  decomposition  is 
manifest,  it  attracts  flies  of  the  species  Lucilla  and  Sarcophaga.  After 
three  or  four  months  the  fat  of  the  cadaver  is  attacked  by  species  of 
Coleoptera  and  Lepidoptera.  After  eight  months  a  new  species  of  fly 
and  a  variety  of  Coleoptera  are  found,  such  as  commonly  sul)sist  u]>on 
decaying  cheese.  When  the  soft  parts  have  been  converted  into  a 
semifluid  mass,  a  fifth  group  of  flies,  Ophera,  Phora,  and  Tyreophora, 
is  found. 

From  eighteen  months  to  two  years  beetles,  of  the  species  Silj)ha 
and  Hister,  and  some  moths,  absorb  the  moist  and  soft  remains.  In  the 
third  year  insects  which  subsist  upon  dry  tissues,  such  as  the  skin  and 
fascia,  princii)ally  of  the  variety  Anthemis,  make  their  appearance. 
Finally,  after  the  fourth  year,  there  may  be  seen  beetles,  of  the  species 
Tenebrio  and  Plinus,  which  subsist  u])on  the  detritus  left  by  previous 
insects,  and  consisting  principally  of  their  chrysalides  and  excrement.-^ 

Other  investigators  have  not  completely  substantiated  this  chrono- 
logic table  of  Megnin's.  Laboulbere  '  finds  that  the  exact  time  and 
order  of  the  appearance  of  these  groups  are  modified  by  the  season  of 
the  year,  the  size  of  the  cadaver,  and  the  locality  where  it  lies.  It 
would  appear,  therefore,  that  the  entomology  of  the  cadaver  depends 
U]>on  the  stage  and  progress  of  putrefaction,  and  as  this  has  l)een  shown 
to  be  a  variable  process,  the  study  of  the  insi^ct  life  of  the  cadaver 
becomes  a  very  intricate  subject,  and,  re(|uiring  as  it  does,  the  services 
of  an  expert  entomologist,  this  interesting  in(pnry  can  rarely  be  pursued 
and  can  at  best  serve  only  as  corroborative  evidence  of  the  period  of 

^  These  de  Paris,  1887,  cited  in  Virchotv's  Jahresbericht,  1888,  S.  467. 

"  BuUetbi  dc  f'Aca/le>»ie,  xx.xii.,  p.  34. 

^  See  Megnin,  La  Faune  des  Cadavres,  Paris,  1894.  *  Ibid. 


136  THE    SIGNS    OF    DEATH. 

death.     Nevertheless,  in  so  far  as  it  aids  the  explanation  of  the  process 
of  decay  in  the  cadaver,  it  is  a  distinct  advance  in  our  knowledge. 

Adipocere. — In  a  considerable  proportion  of  bodies  buried  in 
moist  earth  or  submerged  in  water  the  course  of  decomposition  and 
destruction  of  tissue  will  be  interrupted  by  the  formation  in  the  tissues 
of  a  whitish,  solid,  soapy  substance,  called  adipocere.  The  formation 
of  adipocere  represents  a  true  saponification  of  the  fat  contained  in  the 
tissues.  It  is  found  on  analysis  to  contain  either  calcium  or  ammonia, 
in  combination  witli  the  fatty  acids — oleic,  palmitic,  and  stearic. 

In  its  physical  properties  adipocere  is  a  hard,  brittle,  nearly  struc- 
tureless mass,  with  an  oifensive  odor.  When  containing  calcium  it  is 
whiter  than  when  formed  with  ammonia,  l)ut  it  may  be  secondarily  dis- 
colored yellowish  or  brown.  It  is  lighter  tlian  water,  melts  at  200°  F., 
giving  off  ammonia,  and  after  incineration  leaves  an  earthy  residue. 
Adipocere  is  a  very  permanent  body,  entirely  resisting  the  ordinary 
agents  of  })utrefaction,  and  has  been  found  by  Karlinski  to  be  free  from 
bacteria  when  the  surrounding  tissues  were  swarming  wnth  putrefactive 
organisms.  AVhile  usually  entirely  structureless,  Kratter  has  observed 
that  when  this  substance  rejilaces  muscle  tissue  there  may  be  faint 
indications  of  the  striations  of  the  muscle-fiber  to  be  detected  in  the 
adipocere. 

The  formation  of  adipocere  requires  essentially  a  tissue  containing 
fat,  and  setting  free  fatty  acids  and  an  alljuminous  tissue,  which,  by 
putrefaction,  develops  ammonia.  The  fatty  acids  are  readily  supplied 
from  the  adipose  tissue  of  the  body,  and  it  is  a  well-established  fact 
that  the  transformation  into  adipocere  is  most  complete  in  very  fat 
bodies.  It  has  long  been  a  matter  of  dispute  whether  fatty  acids  may 
be  developed  from  muscle  and  other  tissues  in  which  the  quantity  of 
fat  must  usually  be  small,  and  it  has  been  claimed  that  the  appar- 
ent saponification  of  muscle  is  correctly  explained  by  the  destruction 
of  the  nuiscle  tissue  and  the  subsequent  flow  of  fluid  fat  into  the 
spaces  thus  emptied.  But  in  addition  to  the  fact  that  most  tissues  con- 
tain more  or  less  fat,  and  that  during  life  they  are  subject  to  fatty 
degeneration,  which  is  a  frequent  result  of  fatal  disease,  it  has  been 
shown  bv  Voit  and  Ber^eat  ^  that  fattv  acids  mav  develop  in  muscle 
tissue  that  has  been  placed  in  lime-water  to  prevent  bacterial  growth. 
This  observation  greatly  increases  the  probability  that  muscle  tissue 
may  be  partly  transformed  into  and  not  merely  replaced  l)y  adipocere. 
This  view  is  now  generally  accepted,  although  so  good  an  autliority  as 
Hofl'man  has  been  of  the  contrary  opinion.  The  transformation  of 
muscle  substance  into  fat  and  adipocere  is,  however,  in  strict  accordance 
with  numerous  other  examples  of  the  production  of  hydrocarbons  from 
nitrogenous  principles  of  the  animal  body.  The  ammonia  necessary 
for  saponification  results  from  the  decomposition  of  the  nitrogenous 
elements  of  the  body. 

Hoppe-Seyler  regards  the  formation  of  adipocere  as  the  result  of 
the  action  of  a  special  ferment. 

^  Munchener  medicinische  Wochenschrift,  1888,  S.  518. 


.      CADAVERIC   CHANGES.  137 

The  occurrence  of  adipocere  i^*  subject  to  tlie  same  wide  variations  as 
are  the  other  ])rocesses  of  })utrefaction.  The  jnost  favorable  conditions 
for  its  formation  are  found  in  the  bodies  of  fat  and  youn*;'  indivi(UiaIs, 
and  in  bodies  immersed  in  running  water.  The  most  complete  trans- 
formation into  adipocere  is  seen  in  bni'ial-grounds  where  tiie  soil  is 
moist  and  where  a  large  number  of  bodies  have  been  placed  in  close 
proximity  to  one  another.  It  is  rarely  seen  in  bodies  buried  in  sand  or 
gravel.  Of  the  diiferent  parts  of  the  body,  tho^e  tirst  att'ected  are  natu- 
rally the  tissues  and  organs  containing  the  most  fat,  as  the  subcutaneous 
tissues,  the  breasts,  cheeks,  kidneys,  and,  later,  the  muscles. 

The  time  recpiired  for  the  formation  of  adipocere  is  also  variable. 
Complete  saponification,  according  to  Devergie,  re(iuires  at  least  one 
year  when  tiie  body  lies  in  water,  and  three  years  when  it  is  buried 
in  the  earth.  Caspar  states  that  any  considerable  formation  of  adipocere 
requires  at  least  three  months  in  water  or  six  months  in  the  earth. 

Tidy  refers  to  evidence  that  adipocere  may  form  in  small  quantities 
as  early  as  six  weeks,  or  even  four  weeks,  after  sul)mersion.  His  cases 
also  include  the  complete  saponification  of  the  body  of  an  infant  after 
six  weeks'  submersion,  the  extensive  formation  of  adipocere  in  a  body 
buried  four  months  in  a  dry  soil,  and  the  remarkable  case  of  Billroth's, 
in  Avhich  the  entire  body  of  an  extra-uterine  fetus,  completely  trans- 
formed into  adipocere  in  the  abdomen  of  the  mother,  was  removed  by 
laparotomy. 


SUDDEN  DEATH. 


The  complete  scope  of  the  medicolegal  conception  of  sudden  death 
is  perhaps  best,  though  imperfectly,  seen  in  the  service  of  coroners  of 
large  cities  who  are  expected  to  investigate  the  causes  of  death  in  a 
large  variety  of  cases  of  which  little  is  known  except  that  the  subjects 
were  "  found  dead." 

Of  the  deaths  thus  encountered,  the  larger  proportion,  resulting  from 
violence  or  poisoning,  are  elsewhere  considered,  the  present  section  being 
concerned  with  the  natural  or  internal  causes  of  sudden  death. 

The  classification  of  suddeu  deaths  must,  for  the  present  purpose, 
include  many  instances  in  which  the  pathologic  process  has  not  been 
extremely  acute  or  entirely  free  from  pronounced  symptoms,  and  in 
which  the  death  could  not  have  been  regarded  as  sudden  had  the  patient 
been  under  the  ol>servation  of  a  physician.  There  is,  for  illustration, 
little  real  similarity  between  the  death  of  a  young  woman  overcome  by 
fatal  syncope  on  the  floor  of  a  ball-room,  and  that  of  a  street-rounder 
who  finally  drops  dead  after  struggling  for  days  against  an  extensive 
pneumonia.  Yet  both  are  equally  proper  subjects  for  legal  inquiry, 
and  on  acconnt  of  the  rapidity  of  the  fatal  terminations  both  must  be 
regarded  as  examjiles  of  sudden  death. 

The  old  classification  of  Bichat  of  the  modes  of  death,  as  beginning 
at  the  heart  by  syncope,  or  at  the  head  by  coma,  or  at  the  lungs  by 
asphyxia,  was  the  natural  outgrowth  of  the  teachings  of  Aristotle,  ISIor- 
gagni,  and  Galen,  and  was  the  first  attempt  to  recognize  the  order  in 
which  the  different  organs  and  systems  were  involved  in  the  process  of 
disease  and  the  series  of  events  through  which  certain  lesions  must  prove 
fatal. 

Death  is,  however,  rather  infrequently  the  result  of  an  exclusive 
aifection  of  the  circulatory,  the  respiratory,  or  the  nervous  systems,  and 
it  seems  much  more  logical  at  the  present  day  to  discuss  the  causes 
of  death  in  connection  with  the  viscera  principally  involved  in  the 
lesion. 

Yet  even  such  a  scheme  can  necessarily  serve  only  a  temporary  pur- 
pose, for  the  continued  investigation  of  organic  disease  is  constantly 
enlarging  and  readjusting  ideas  as  to  the  relative  importance  of  the 
various  visceral  lesions  associated  in  these  diseases.  In  the  present 
state  of  the  knowledge  of  pathology  one  rests  content  when  some  mor- 
phologic change  in  the  structure  of  a  viscns,  which  it  is  the  custom 
to  call  a  fatal  lesion,  is  discovered.  Of  the  links  in  the  chain  which 
connects  this  lesion  with  the  cessation  of  the  com]ilex  process  of  life 
one  is  for  the  most  part  in  ignorance,  and  the  inability  to  point  out  the 

138 


VISCERAL    CHANGES    LEADING    TO    SUDDEN    DEATH.  139 

essential  relation  between  change  of  structure  and  alteration  of  function 
in  a  cell  or  viscus  renders  it  often  a  matter  of  conjecture  to  decide  w  hat 
constitutes  a  iatal  lesion  or  whicii  of  many  lesions  is  the  essential  cause 
of  death.  For  instance,  sclerotic  kidneys  are  sometimes  found  at 
autopsy  as  an  unimportant  and  secondary  lesion  in  ])ersons  dying  with- 
out renal  symptoms,  although  this  lesinn,  under  many  circumstances, 
would  be  at  once  accej)ted  as  the  cause  of  death.  Yet  in  neither  case 
would  the  mere  presence  of  connective  tissue  in  the  kidney  give  an 
explanation  of  the  death  of  the  patient.  Even  more  (HtHcult  is  the 
problem  wlien  dealing  with  eases  of  death  from  some  })oisons  which 
leave  no  morphologic  evidence  yet  demonstrated  of  their  fatal  action. 
So  that  it  nuist  be  confessed  that  in  some  cases  it  is  impossiljle  to  tind 
any  trace  of  the  manner  or  cause  of  death,  and  in  otiier  cases  to  demon- 
strate any  necessarily  fatal  result  of  existing  lesions. 

Such  considerations  may  serve  to  indicate  the  wide  gap  that  exists 
in  the  knowledge  between  the  structural  characters  of  viscera  and  the 
phenomena  of  life,  and  until  this  gap  has  been  bridged  over  no  final 
plan  of  classification  of  the  causes  of  death  can  be  constructed.  Never- 
theless it  will  not  l^e  well  to  retain  a  scheme  which  recognizes  only  the 
crudest  notions  of  symptomatology  and  ignores  the  present  knowledge 
of  the  essential  pathologic  basis  of  disease. 

CONSIDERATION  OF  THE  VISCERAL  CHANGES  LEADING 

TO  SUDDEN  DEATH. 

Heart  and  Blood-vessels. — Of  the  viscera  in  which  organic 
or  functional  disturbance  leads  to  sudden  death,  the  heart  and  blood- 
vessels are  tliose  most  frequently  affected.  In  1000  deatlis  reported 
by  Westcott,^  of  which  303  were  entirely  unexpected,  210  resulted 
from  syncope,  64  from  asphyxia,  and  29  from  coma. 

Organic  disease  of  the  heart,  frequently,  though  in  a  smaller  per- 
centage than  is  often  believed,  terminates  in  sudden  and  unexpected 
death.  Valvular  lesions  of  the  heart  usually  induce  a  Mell-marked 
train  of  synn)toms  ending  in  gradual  asthenia,  less  comuKmly  in  fatal 
suffocative  attacks.  Aortic  stenosis  and  insufficiency,  however,  not 
infrequently  terminate  in  sudden  death  when  the  general  condition  of 
the  ])atient  gives  little  suspicion  of  such  danger.  Sudden  muscular 
exertion  or  extreme  mental  emotion  is  the  usual  immediate  cause  of  the 
fatal  attack.  Other  forms  of  valvular  disease,  even  without  s]iecial 
complications,  may  occasionally  end  in  sudden  death. 

Cardiac  thrombi,  arising  usually  from  endocarditis,  may  gradually 
become  elongated  or  detached,  and  lodged  in  the  orifices  of  the  heart, 
when  the  disturbance  of  the  heart's  action  which  ordinarily  results  from 
their  presence  instantly  liecomes  extreme  and  ])roves  rajiidly  fatal. 
When  portions  of  vegetations  of  the  diseased  valves  are  lodged  as 
emboli  in  the  arteries  of  the  brain,  death  may  result  very  soon,  although 
the  usual  course  in  such  cases  is  more  prolonged.  When  the  coronary 
1  British  Medical  Journal,  Oct.  17,  189L 


140  SUDDEN    DEATH. 

arteries  are  similarly  occluded,  death  may  be  more  rapid,  a  fact  of 
which  the  complete  exjierimental  proof  has  been  recently  fui-nished  by 
Porter.^  Stenosis  of  the  coronary  arteries  does  not  usually  of  itself 
lead  to  sudden  death,  but  may  ])roduce  extensive  fibroid  changes,  most 
frequently  in  the  wall  of  the  left  ventricle,  which  may  terminate  in 
sudden  heart  failure  or  rupture. 

Interstitial  or  fatty  myocarditis,  with  or  witliout  valvular  lesions, 
is  the  usual  form  of  heart  disease  terminating  in  sudden  death.  It  is 
probable  that  alterations  in  the  nervous  apparatus  of  the  heart  are  partly 
concerned  in  the  sudden  failure  of  the  heart  so  frequently  seen  in  these 
conditions  (Kuszeuow).-^  In  addition  to  the  fatty  degeneration  of  the 
heart  muscle  associated  with  myocarditis  there  may  be  a  marked  increase 
of  the  subpericardial  fat,  Aviiich  encroaches  on  and  infiltrates  the 
heart  muscle  and  may  lead  to  extreme  atrophy  of  the  walls,  especially 
in  the  auricles.  This  condition  is  usually  found  in  fat  persons  who 
suffer  from  palpitation  and  dyspnea,  and  who,  having  some  violent  dis- 
turbance of  the  circulation,  may  suddenly  die.  Brouardel  ^  has  observed 
this  condition  in  poorly  nourished  children  who  died  from  the  effects  of 
the  cold  bath. 

Tuberculous  myocarditis,  usually  in  association  with  slight  or 
advanced  pulmonary  tuberculosis,  may  be  an  unexpected  discovery  at 
autopsy  in  case  of  very  sudden  death  occurring  in  various  stages  of 
phthisis,  and  has  been  noted  without  the  pulmonary  lesion  (Kolisko, 
Hofltman). 

Rupture  of  the  heart=wall  may  suddenly  terminate  an  old  car- 
diac lesion,  the  rupture  being  almost  invariably  preceded  by  myocar- 
ditis, endocarditis,  or  anemic  infarction.  Even  rupture  of  the  heart  is, 
however,  not  always  immediately  fatal,  life  being  prolonged  for  several 
hours  when  the  blood  takes  a  circuitous  course  through  the  cardiac 
muscle  before  reaching  the  pericardium.  As  in  the  case  of  rupture  of 
aortic  aneurysms,  anemia  is  not  the  sole  cause  of  death,  which  is  here 
.due  principally  to  distention  of  the  ]tericardium  and  pressure  njion  the 
right  side  of  the  heart.  Rupture  of  a  valve  or  a  chorda  tendinea 
usually  causes  very  urgent  symptoms,  and  has  been  known  to  result  in 
almost  instant  death  (Councilman).* 

In  a  considerable  class  of  cases  in  which  the  pathologic  findings 
include  myocarditis,  endocarditis,  sclerosis  of  the  coronary  arteries, 
atheroma  of  the  aorta,  and  changes  in  the  cardiac  plexus  of  nerves, 
sudden  death  occurs  with  the  peculiar  complex  of  symptoms  called 
angina  pectoris. 

Adherent  pericardium  has  been  the  sole  pathologic  condition  recog- 
nized in  many  cases  of  sudden  death.  Whether  this  condition  alone  is 
capable  of  inducing  a  fatal  issue  may  be  doubted,  and  it  is  the  opinion 
of  the  best  authorities  that  adherent  pericardium  cannot  stand  alone  as 
a  cause  of  death.     But  there  can  be  no  doubt  that  adherence  of  the 

^  Journal  of  Erj)rrimentnl  Aledicine,  1896,  No.  1. 

^  Virchoiv'fs  Archiv,  Bd.  cxxxii.,  S.  1.  •''  Death  and  Sudden  Death,  p.  126. 

*  Boston  Medical  and  Surgical  Journal,  1893,  p.  457. 


VISCERAL    CHANGES    LEAD1N(;    TO    SUDDEN    DEATH.  141 

pericanliiim  may  be  very  early  followed  by  chanjjes  in  the  heart  mu.scle 
and  by  (.-hronic  oonsxestion  of  tlic  viscera,  tiie  combination  of  which, 
under  favorable  circumstances,  such  as  violent  exertion  or  acute  disease, 
has  resulted  in  sudden  death.  The  demonstration  of  such  secondary 
chauii'es  may,  liowever,  escape  detection  by  the  naked  eye  and  nijuire 
a  careful  microscopic  examination. 

In  addition  to  the  orii'anic  diseases  of  the  heart  just  named  in  which 
adcfjuate  patliologic  changes  may  be  demonstrated,  sudden  death  occurs 
witli  sym})tonis  of  cardiac  failure  in  a  considerable  luunber  of  cases  in 
whicii  no  satisfactory  structural  changes  in  the  heart  have  Ijcen  dis- 
covered, and  which  must  be  referred  to  functional  disturbance  of  the 
heart's  action. 

Shock. — Usually  in  youjig  or  in  old  ami  eni'eel)led  persons,  after 
severe  injuries,  with  or  without  hemorrlnige,  sometimes  after  surgical 
operations,  sudden  death  may  occtn-  in  the  absence  of  any  satislactorv 
pathologic  basis  that  has  yet  been  discovered,  and  with  a  somewhat 
peculiar  combination  of  symptoms  called  sJiock.  The  ])athologv  of  this 
condition  is  imperfectly  understood,  but- is  partly  exjilained  1)V  the  well- 
known  experiment  of  Galtz,  who,  by  repeated  blows  on  the  abdomen 
of  frogs,  produced  complete  arrest  of  the  heart  and  dilatation  of  the 
abdominal  vessels  to  sixteen  times  their  usual  capacity.  It  would  thus 
appear  that  in  some  cases,  at  least,  shock  is  essentially  a  vasomotor  and 
cardiac  paralysis.  After  death  from  this  cause  the  autojisy  may  reveal 
nothing  but  an  abnormal  blood  content  in  the  abdominal  veins,  a  con- 
dition of  which  it  is  rather  difficult  to  judge. 

Syncope  is  a  term  applied  to  a  condition  closely  allied  to  shock, 
both  presenting  in  a  very  similar  degree  cardiac  weakness  and  arterial 
anemia.  The  indefinite  character  of  both  terms,  fthork  and  .'<ipicojM', 
renders  it  difficult  to  determine  in  every  case  whether  death  should  l»e 
referred  to  one  or  to  the  other,  and  often  reduces  tiie  decision  to  a 
matter  of  conjecture,  as  the  following  case-  will  illustrate.  Deutsch^ 
reports  the  sudden  death  of  a  woman,  twenty-one  years  old,  after  one 
minute's  submersion  in  cold  water  for  baptism.  Immediately  after  the 
ceremony  the  girl  sank  down  unconscious  in  the  dressing-room  and  died. 
The  autopsy  revealed  no  organic  lesions,  and  death  was  attributed  to  the 
cold  water  and  the  mental  excitement  of  the  ceremony.  It  would  be 
difficult  to  determine  in  this  instance  M'hether  death  should  be  assigned 
to  shock  from  tlie  cold  water  or  to  simple  heart  failure  from  the  same 
cause  and  the  coincident  mental  excitement. 

It  would  be  strictly  in  accordance  with  the  present  application  of  the 
term  to  attribute  to  syncope  the  sudden  death  of  ]iatients  convalescent 
from  pneumonia,  who  have  been  known  to  fall  dead  when  making  con- 
sideral)le  muscular  exertion,  as  in  sitting  u])right  in  bed.  Here  the 
combination  of  cardiac  weakness  and  cerebral  anemia  is  sufficient  to 
induce  death,  and  the  element  of  shock  cannot  be  said  to  enter. 

Probably  a  large  proportion  of  the  cases  of  fatal  syncope  are  refera- 
ble to  organic  changes  in   the  heart  and  arteries,  which  manifest  them- 

1  Zeitschrift fur  Medicin,  1891,  S.  V?,l . 


142  SUDDEN    DEATH. 

selves  ouly  under  the  influence  of  some  peculiar  exciting  cause.  The 
autopsy  may  then  reveal  the  organic  basis  of  a  disturbance  which  may 
have  appeared  purely  functional.  At  other  times  tatal  syncope  occurs 
in  the  absence  of  any  anatomic  change  as  yet  demonstrated  in  the  heart, 
blood-vessels,  or  nervous  system,  and  the  results  of  postmortem  exam- 
ination thus  far  are  entirely  negative.  It  is  even  reported  that  nms- 
cular  exertion  and  mental  emotion  alone  have  led  to  sudden  death  of 
persons  in  sound  health.  To  any  such  t^upposition  an  emphatic  protest 
must  be  entered,  otherwise  the  doors  are  left  open  to  the  extremes  of 
popular  fancy  in  regard  to  the  actual  conditions  existing  in  such  obscure 
cases. 

It  appears  that  peripheral  sensory  irritation  may  sometimes  produce 
a  fatal  combination  of  shock  and  cardiac  paralysis,  of  which  the  follow- 
ing cases  may  serve  as  illustration  :  Vibert '  has  reported  the  sudden 
death  of  a  young  woman,  four  montlis  j)regnant,  while  a  small  cannula 
was  being  inserted  into  the  uterus  to  produce  abortion.  He  refers  also 
to  other  cases  of  sudden  death  after  uterine  douches.  Bonvalot  ^  reports 
several  cases  of  sudden  death  during  manipulation  of  the  pregnant 
uterus,  and  considers  the  deaths  to  be  referable  to  reflex  inhibition  of 
the  heart's  action  and  of  respiration.  Brouardel  refers  to  several  cases 
of  sudden  death  occurring  after  simple  vaginal  examination.  Great 
caution  must  be  exercised,  however,  bef  )re  concluding  that  death  has 
not  resulted  from  some  deflnite  and  adequate  mechanical  condition  or 
other  lesion  which  is  produced  by  or  is  coincident  m  ith  such  minor  pro- 
cedures. Hoffiuan  demonstrated  a  considerable  injury  to  the  placenta 
and  an  extensive  pulmonary  embolus  in  a  case  of  sudden  death  follow- 
ing the  injection  of  hot  water  into  the  uterus.  A  very  careful  post- 
mortem examination  is  therefore  required  before  such  mechanical  causes 
of  death  can  be  excluded  and  the  fatalities  be  referred  to  shock  or 
syncope. 

To  a  somewliat  similar  condition  of  shock  and  svncope  may  be 
attributed  the  deaths  occurring  after  the  sudden  withdraA^d  of  large 
amounts  of  fluid  from  the  abdominal  and  thoracic  cavities.  Catlieter- 
ization  of  the  distended  l)ladder  or  paracentesis  of  the  jieritoneal, 
pleural,  or  pericardial  cavities  has  not  infrequently  been  followed  by 
sudden  heart  failure  and  death.  The  rapid  lowering  of  blood-pressure 
that  follows  the  removal  of  large  amounts  of  fluid  in  these  cavities  is 
chiefly  responsible  for  death  in  such  cases.  To  what  extent  fatalities 
attributed  to  shock  and  syncope  are  referable  to  the  eonstitutio  lym- 
phatica,  to  be  considered  later,  is  an  important  matter  for  future  inves- 
t  location. 

While  in  shock  and  syncope  the  arterial  anemia  results  from  cardiac 
weakness,  in  hemorrhage  the  arterial  anemia,  due  to  actual  loss  of 
blood,  is  the  cause  of  cardiac  weakness  and  syncope.  The  sym])toms 
of  the  two  conditions  are,  therefore,  more  or  less  similar,  but  the  find- 
ings at  autopsies  are  quite  difl'erent,  the  central  veins  being  overfilled 
after  deatli  from  shock  and  syncope,  while  in  death  from  hemorrhage 

'  A7inales  d' Hygienes publiques,  1890,  xxiv.,  p.  541.         ^  Ibid.,  xxviii.,  p.  444. 


VISCERAL    CHANGES    LEADING    TO    SUDDEN    DEATH.  143 

the  blood  content  of  all  the  viscera  and  vessels  is  uniforinlv  diniin- 
islied. 

Bxternal  hemorrhage  as  a  cause  of  sudden  death  is  easily 
recognized,  hut  the  bleeding  may  take  place  into  the  cavities  or  hollow 
viscera  of  the  body,  when  death  occurs  with  symptoms  of  anemia  and 
syncope,  but  without  any  apparent  loss  of  bhxxl.  Well-known  ex- 
amples of  this  maimer  of  sudden  dcatii  are  seen  in  the  rupture  of 
extra=uterine  fetal  sacs,  in  the  concealed  intestinal  hemorrhages  of 
typhoid  fever,  and  in  the  rupture  of  internal  aneurysms.  The  blood 
in  pulmonary  hemorrhage  may  be  swallowed,  and  sudden  death  may 
result  without  hemoptysis.  Fatal  concealed  hemorrhage  into  the 
stomach  and  intestines  may  result  from  ulcer  of  the  stomach  or  from 
the  congestion  produced  by  a  cirrhotic  liver,  while  some  diseases  of  the 
blood  attended  with  severe  anemia  may  prove  suddenly  fatal  at  any 
time  from  internal  hemorrhage,  usually  into  the  stomach  and  intestines. 
Xew-born  infants  are  especially  liable  to  perish  suddenly  from  internal 
hemorrhage  into  the  hollow  viscera  or  cavities.  Such  hemorrhages  in 
the  new-born  may  be  due  to  hemophilia  and  to  venous  congestion  from 
asphyxia,  and  it  appears,  from  the  researches  of  Tizzoni  and  Giovan- 
niui,  Babes,  Neumann,  and  others,  that  they  are  often  the  result  of 
infection  with  pathogenic  bacteria. 

The  extent  of  hemorrhage  required  to  induce  death  varies  with  the 
age  and  strength  of  the  patient.  It  is  generally  stated  that  the  loss  of 
one-quarter  of  the  total  volume  of  blood  will  prove  fatal.  Children 
are  much  more  susceptible  to  the  effects  of  hemorrhage  than  are  adults, 
and  at  any  age  a  very  rapid  hemorrhage  is  much  more  dangerous  than  a 
gradual  loss  of  the  same  quantitv  of  blood. 

Diseases  of  the  arteries  may  tend  to  sudden  death  either  by 
the  formation  and  ruptiu'c  of  aneurysms  or  by  secondary  disturbances 
in  the  circulation. 

Arteriosclerosis  affects  every  age  after  puberty,  and  the  obscure 
character  of  the  symptoms,  even  in  the  presence  of  advanced  lesions, 
renders  the  disease  a  common  cause  of  unexpected  death.  The  marked 
frequency  with  which  the  lesion  is  found  principally  or  exclusively  in 
a  single  system  of  vessels,  as  the  cerebral,  pulmonary,  or  aortic  sys- 
tems, adds  to  the  difficulty  of  determining  the  real  condition  of  the 
patient  as  judged  by  the  state  of  the  superficial  vessels  and  the  urgency 
of  the  symptoms.  Thrombosis,  embolism,  and  the  ruj)tur(>  of  aneurysms 
are  the  usual  terminations  in  such  cases.  But  these  accidents  do  not 
always  prove  immediately  fatal.  A  period  of  some  hoin's  or  days 
usually  elapses  before  death  in  the  fatal  cases,  except  when  the  infarcted 
area  or  hemorrhage  is  very  large  and  is  situated  in  the  medulla. 
Almost  instantaneous  death  usually  follows  the  ru])ture  of  large  aortic 
aneurysms,  the  blood-pressure  falling  so  rapidly  that  the  (piantity  of 
escaped  blood  found  at  autopsy  may  be  so  small  as  to  indicate  that  death 
had  not  resulted  from  hemorrhage  alone. 

Rupture  of  the  aorta  may  occur  and  lead  to  sudden  dc^ath  in  the 
absence  of  marked  alteration   in   the  vessel-walls,  but  is  usually  found 


144  SUDDEX  DEATH. 

associated  with  the  cardiac  hypertrophy  and  arteriosclerosis  of  chronic 
nephritis. 

Traumatic  rupture  of  internal  arteries,  without  extensive  ontAvard 
injury,  may  lead  to  sudden  death,  which  might  readily  be  referred  to 
the  shock  of  the  injury.  InHammatory  changes  in  the  neighborhood 
of  large  arteries  sometimes  lead  to  sudden  and  fatal  rupture  of  these 
arteries.  Tidy  refers  to  2  cases  of  perforation  of  the  aorta  and  of  the 
vertebral  artery  resulting  from  angular  curvature  of  the  spine. 

The  toxic  condition  of  the  blood  to  which  acute  uremic  seizures  are 
probably  to  be  referred  is  associated  with  attacks  of  spasmodic  con= 
traction  of  the  arteries,  which  are  undoubtedly  an  important  factor  in 
the  fatal  termination  so  frequently  seen  in  this  condition. 

Some  obscure  cases  of  sudden  death  are  attributable  to  inflamma- 
tion, thrombosis,  and  embolism  of  the  veins.  Occlusion  of 
the  cerel)ral  sinuses  or  of  many  of  the  cerebral  veins  may  result  fatally, 
but  usuallv  only  after  an  interval  of  some  davs.  There  are  on  record 
a  number  of  sudden  deaths  due  to  the  loosening  of  a  clot  from  some 
inflamed  peripheral  vein  and  its  lodgement  in  the  right  heart  and 
pulmonary  artery.  Very  slight  manipulation  of  the  affected  limb  has 
been  sufficient  in  these  cases  to  detach  the  masses  of  coagulum  which 
are  loosely  held  in  the  inflamed  vessel.  After  parturition  clots  from 
the  uterine  sinuses  have  been  carried  to  the  pulmonary  arteries,  pro- 
ducing extensive  occlusion  of  these  vessels  and  leading  to  very  sud- 
den death.  It  is  })robable  that  phlebitis  and  thrombosis  are  more  fre- 
quent complications  of  gonorrhea  in  the  female  than  is  at  present  recog- 
nized, and  that  the  unexpected  fatal  termination  of  some  of  the  cases 
recently  reported  flnds  its  true  explanation  in  pulmonary  embolism  from 
this  source. 

The  entrance  of  air  into  the  veins  is  a  rapidly  fatal  accident  of 
infrequent  occurrence.  It  is  most  often  encountered  in  operations  about 
the  great  vessels  of  the  neck.  When  the  wall  of  the  vein  or  the  sur- 
rounding  connective  tissue  is  inflamed,  thickened,  and  rigid,  the  vessel 
does  not  collapse  readily  after  incision,  and  the  suction  force  of  the  heart 
may  then  suffice  to  draw  into  the  right  ventricle  a  considerable  quantity 
of  air.  The  presence  of  this  volume  of  gas  interrupts  the  current  of 
blood  and  its  passage  through  the  lungs,  and  death  results  with  great 
rapidity.  A  similar  accident  has  been  claimed  to  be  the  probable  cause 
of  death  after  an  intra-uterine  douche. 

The  importance  of  fat  embolism  as  a  cause  of  sudden  death  after 
injury  has  gained  increasing  recognition  since  the  first  demonstration, 
by  Zenker,  of  fluid  fat  in  the  pulmonary  capillaries  after  rupture  of  the 
stomach  and  liver.  The  principal  origin  of  the  fatty  emboli  was 
believed  to  be  foci  of  pus  which  had  undergone  fatty  degeneration,  until 
it  was  shown  by  Busch  ^  that  its  usual  point  of  origin  is  the  bone-mar- 
row. From  the  cases  cited  by  Wintritz,'^  it  appears  that  injuries  of 
soft  parts  containing  fat  may  be  a  source  of  extensive  fat  embolism, 

1    Virchov)' s  Ai-chires,  1866,  vol.  xxxv. 

^    Vierteljahresschriftfiir-  gerichtliche  Medicin,  1896,  p.  47. 


VISCERAL    CHANGES    LEADING    TO    SUDDEN    DEATH.  145 

while  Virchow  ^  found  in  the  crushing  of  pelvic  adipose  tissue  a  pos- 
sible cause  of  some  fatal  cases  of  eclampsia  in  which  fat  onilx)!!  were 
discovered  in  the  lun&s. 

The  fatal  process  in  fat  embolism  may  readily  be  IblloMcd,  as 
described  by  Cohnheim.-  Passing  from  the  site  of  the  injury  into  the 
open  mouths  of  the  veins  (or  lymphatics,  Busch),  the  fluid  fat  is  lodged 
in  the  capillaries  of  the  lungs,  and  less  abundantly  in  the  kidneys,  brain, 
heart,  liver,  etc. 

Owing  to  the  extensive  occlusion  of  the  pulmonary  capillaries,  the 
venous  blood  is  unable  to  pass  through  the  lungs,  and  the  right  heart 
and  general  venous  system  become  engorged  with  blood,  while  the  blood 
content  of  the  right  side  of  the  heart  is  ffreatlv  reduced.  Then  follow 
venous  transudation  and  capillary  hemorrhages,  which  are  apparent  to 
the  naked  eye  in  the  excessive  pulmonary  edema  and  in  the  punctate 
hemorrhages  seen  on  the  pleural  surfaces  and  throughout  the  parenchyma 
of  the  lung.  Occasionally  ecchymoses  of  similar  origin  may  be  found 
in  the  viscera,  in  the  brain,  pia  mater,  mucous  membranes,  and  con- 
junctiva. The  occurrence  of  emboli  in  the  general  venous  system  is 
regarded  as  the  sole  cause  of  death  from  fat  embolism  by  Scriba,  who 
denies  that  pulmonary  embolism  of  this  character  can  ever  be  so  exten- 
sive as  to  produce  death.  This  belief  is  not  generally  accepted,  and 
the  cases  reported  by  von  Bergman,  Czerny,  and  others  ^  indicate  that 
death  is  caused  by  pulmonary  edema  and  venous  stasis. 

The  presence  of  a  moderate  amount  of  fat  in  the  capillaries  of  the 
lungs  and  other  viscera  is  not,  alone,  a  certain  proof  that  this  condition 
has  been  the  cause  of  death.  It  has  been  shown  by  Scriba*  that  a 
moderate  grade  of  general  fat  embolism  may  be  found  after  death  from 
pyemia,  chronic  osteomyelitis,  or  chronic  suppuration,  when  the  entrance 
of  fat  into  the  circulation  is  of  secondary  importance.  Therefore  it  is 
only  when  the  obstruction  of  the  pulmonary  capillaries  is  extensive  that 
the  presence  of  fat  embolism  can  be  regarded  as  an  important  factor  in 
the  fatal  issue.  Yet,  according  to  Virchow  and  AVintritz,  a  moderate 
grade  of  fat  embolism  may  induce  death  in  subjects  who  have  been 
weakened  by  disease  or  hemorrhage. 

In  order  completely  to  establish  the  diagnosis  of  fat  embolism  as  the 
cause  of  death  it  is  required  that  the  clinical  history  should  furnish  a 
probable  cause,  such  as  a  severe  injury,  with,  or  ])ossibly  without, 
fracture  of  bones  or  crushing  of  soft  parts  ;  that  the  manner  of  death 
should  indicate  an  obstruction  of  the  jmlmonary  circulation  ;  and  that 
the  microscopic  examination  of  the  lungs  and  other  viscera  should  dis- 
close an  extensive  engorgement  of  the  capillaries  with  fluid  fat. 

The  recent  studies  of  Ribbert  ^  indicate  that  fat  embolism  may  be 
a  more  frequent  and  important  occurrence  than  has  previously  been 
supposed.     This   investigator,  after  repeated  blows    upon   the  tibia   in 

^  Berliner  klinische  Woehenschrift,  1886,  No.  30. 

'  UniermicJiiingen  iiher  die  embolische  Prores.ie.  *  See  Wintritz,  loc.  cit. 

*  Deutsche  Ze'ifschrift filr  Chi7-urgie,  1880,  Bd.  xii. 

*  Correspondenzblait  fiir  die  Schweizer  Aerzte,  1894,  Bd.  xxiv. 

Vol.  I.— 10 


146 


SUDDEN    DEATH. 


healthy  rabbits,  was  able  to  demonstrate  the  presence  of  fat  emboli  in 
considerable  extent  throughout  the  lungs,  brain,  heart,  and  some  other 
tissues,  from  which  he  infers  that,  even  without  fracture  of  bones,  the 
fat  of  the  marrow  may  be  rendered  mobile,  enter  the  circulation,  and 
produce  fat  oml)olism,  with  marked  lesions  in  the  lungs,  brain,  and 
heart.  He  calls  attention  to  the  fact  that  the  quantity  of  fat  found  in 
the  organs  is  apparently  much  greater  than  that  usually  found  crushed 
by  fractures,  indicating  that  it  must  have  been  derived  from  other 
regions  than  the  point  of  fracture.  Ribbert,  therefore,  suggests  that  in 
cases  of  sudden  death  from  violence,  not  adequately  explained  by  the 


Fig.  16.— Peyer's  patch  from  a  case  of  status  lymphaticus  (photograph  by  Dr.  E.  Learning). 

gross  lesions,  the  possibility  of  fat  embolism  should  always  be  con- 
sidered. The  possible  importance  of  tat  embolism  in  traumatic  neu- 
roses is  naturally  suggested  by  these  experiments. 

In  many  cases  of  sudden  death  resulting  through  disturbances  of 
the  circulation  a  special  predisposing  factor  is  believed  by  Reckling- 
hausen, Kolisko,  and  others  to  exist  in  the  presence  of  the  so-called 
<<  constitutio  lymphatica."  The  anatomic  evidence  of  this  ]ihys- 
ical  tendency,  which  is  believed  to  render  the  subject  especially  liable  to 
sudden  death  from  various  causes,  consists  in  a  general  hyperplasia  of 
the  lymphatic  structures  and  spleen,  persistence  of  the  thymus,  hypo- 


VISCERAL    CHANGES    LEADING    TO    SUDDEN    DEATH.  147 

plasia  of  the  laart  and  blood-vessels,  and  occasionally  in  evidences  of 
nieliitis.  It  is  claimed  that  in  a  large  |)roportion  of  nncxpected  deaths 
after  iiilialation  of  chloroform,  after  brief  submersion  in  water,  and 
after  a[)}xirently  inconsiderable  hemorrhages,  these  evidences  of  a  pecu- 
liar ])hysical  constitution  may  be  demonstrated.  In  these  cases,  as 
explained  by  Paltauf,'  disturbances  ol"  the  blood-pressure  and  circula- 
tion are  readily  j)roduced  by  proper  exciting  causes  and  lead  to  sudden 
canliac  paralysis. 

The  belief  in  tlie  importance  of  the  "  constitutio  li/mphatica  "  is  now 
but  universally  accepted ;  it  has  not  been  definitely  shown  what  propor- 
tion of  these  unexpected  deaths  are  and  what  are  not  associated  with 
the  anatomic  peculiarities  just  described. 

An  important  and  obseure  class  of  sudden  fatalities  ])artly  referable 
to  disturbance  of  respiration  is  seen  in  the  almost  instantaneous  deaths 
which  sometimes  follow  sudden  occlusion  of  the  larynx  by  foreign 
bodies.  The  ustial  history  in  such  cases  indicates  that  a  piece  of  meat 
or  other  foreign  l)ody  reached  the  larynx,  more  or  less  completely 
occluding  it,  and  that  the  subject  died  so  soon  after  the  accident  as  to 
})reclude  the  possibility  of  asphyxia,  and  to  suggest  a  form  of  reflex 
cardiac  paralysis  as  the  cause  of  death.  Anatomic  signs  of  the  con- 
sfitutio  lymph dica  have  been   found   in  some  of  these  cases.^ 

Disturbances  of  the  respiration  resulting,  for  the  most  part, 
from  partial  or  com|)lete  oeclusion  of  the  res])iratorv  passages  or  from 
diseases  of  the  hmgs,  are  im])ortant  causes  of  sudden  death. 

Sudden  and  complete  occlusion  of  the  respiratory  passages  is  usually 
the  result  of  violence,  but  children  frequently,  and  adults  occasionally, 
die  from  rapid  stenosis  of  the  larynx  or  bronchi  in  the  course  of  disease. 
Acute  laryngitis  in  the  adult  may  be  complicated  by  sudden  edema  of 
the  larvnx  and  ulottis,  causing  death  at  a  time  when  the  general  condi- 
tion  gives  no  urgent  indication  of  such  danger.  In  the  infant  laryn= 
gismus  stridulus,  with  or  without  an  accompanying  laryngitis,  may 
prove  suddenly  fatal.  In  the  absence  of  laryngitis  the  autopsy  would 
reveal  only  the  evidences  of  asphyxia,  or,  perhaps,  the  signs  of  the 
.status  h/mpJuificust. 

New-born  infants  are  especially  exposed  to  the  danger  of  asphyxia 
from  tiie  inhalation  of  mucus  and  meconium  during  labor,  and  of 
stomach-contents  shortly  after  birth. 

An  enlarged  and  persistent  thymus  is  claimed  by  many  to  be 
directly  responsible  f  )r  some   unexpected  deaths  in  infants  and  children. 

The  possibility  that  an  enlarged  thynuis  might,  by  pressure,  cause 
sudden  asphyxia  was  first  suggested  and  denied  by  Friedleben,  in  1858. 
Important  evidence  against  the  possibility  of  death  by  such  compression 
of  the  trachea  has  been  furnished  by  Scheele,  who  showed  that  a  weight 
of  1000  grams  (2. "2  pounds)  is  usually  required  to  close  the  infant's 
trachea,  and  pointed  out  that  no  instance  liad  yet  been  seen  in  which 

'   Wie?irr  ki'miffche  Wochenschrlff.  1890.  No.  9. 

■^  For  a  fuller  discussion  of  the  lymphatic  constitution,  with  literature,  see  New 
Fork  Medical  Journal,  July  10,  1897. 


148  SUDDEN    DEATH. 

the  trachea  appeared  softened  or  flattened  by  pressure  of  the  tliymus. 
Nevertheless,  cases  of  sudden  death  with  symptoms  of  tracheal 
stenosis  coincident  with  enlargement  of  the  thymus  have  been  so 
numerous  that  it  has  been  necessary  to  admit  the  connection  of  the 
thymus  in  these  cases,  and  to  refer  the  usual  manner  of  death-  to  causes 
other  than  stenosis  by  pressure.  One  of  the  important  recent  studies 
of  the  subject  is  contributed  by  Pt)tt.^  From  an  examination  of  10 
cases  Pott  concludes  that  the  enlarged  thvmus  exerts  a  mechanical 
influence  on  the  heart,  which  may  cause  death.  It  is  shown  that  the 
hyperplastic  gland  usually  lies  upon  the  pulmonary  artery  and  aorta, 
and  covers  the  right  auricle  and  two-thirds  of  the  right  ventricle.  The 
heart  is,  therefore,  subjected  to  direct  pressure  not  only  from  the  weight 
of  the  gland,  which  may  reach  50  grams  (1|  ounces),  but  also  from 
any  acute  swelling  which  may  affect  it.  In  2  of  the  10  cases  there 
was  adherence  of  the  thymus  to  the  [)ericardium,  which  the  author 
believes  to  be  of  considerable  importance.  Not  only  may  the  heart  and 
vessels  be  compressed,  but,  in  Pott's  opinion,  the  enlarged  organ  may 
narrow  the  upper  opening  of  the  thorax,  compress  the  trachea,  and,  by 
pressure  upon  the  vagi  and  recurrent  nerves,  may  cause  spasm  of  the 
glottis,  w^hich  the  clinical  history  indicates  to  be  the  manner  of  death  in 
many  cases. 

In  a  later  critical  study  of  the  subject  Seydel"  recognizes  hyper- 
trophy of  the  thymus  as  a  cause  of  sudden  death  in  infants,  and  gives 
as  a  possible  explanation  spasmodic  laryngismus,  a  rudimentary  form 
of  eclampsia,  exaltation  of  a  cerebral  *'  spasm  center,"  and  cardiac 
paralysis.  A  rather  diiferent  opinion  is  held  by  Paltauf  ^  and  others. 
In  225  cases  of  asphyxia  in  infiuits  Paltauf  did  not  find  that  the 
thymus,  although  often  very  large,  ever  compressed  or  narrowed  the 
trachea.  Bronchitis  was,  however,  a  frequent  cause  of  death  in  these 
cases,  and  w^hen  this  cause  was  wanting,  Paltauf  referred  the  deaths  to 
the  presence  of  the  lymphatic  constitution  already  described,  which,  by 
disturbance  of  the  blood-pressure,  circulation,  and  nervous  system,  may, 
under  proper  exciting  conditions,  lead  to  cardiac  paralysis. 

It  may,  therefore,  be  concluded  that  the  hyperplasia  of  the  thymus, 
or  some  undetermined  condition  usually  associated  with  it,  may  stand  as 
a  cause  of  sudden  death,  as  appears  amply  demonstrated  by  clinical 
reports.  That  the  enlarged  organ  ever  directly  compresses  and  occludes 
the  trachea  may  be  doubted,  and  that  the  real  maimer  of  death  in  some 
of  these  cases  is  to  be  found  in  some  other  inflammatory,  nervous,  or 
mechanical  interference  with  respiration  and  circulation  may  be  con- 
sidered probable. 

An  enlarged  thyroid  compressing  the  larynx  and  trachea  has  occa- 
sionally l)eeu  rc])()rted  as  the  cause  of  sudden  death.  As  with  enlarge- 
ment of  the  thymus,  opinions  are  at  variance  as  to  the  manner  of  death 
from  this  cause.     Death  has  been  referred  to  a  spasmodic  closure  of 

'  Jahrbiiche?'  fiir  Klnde7'heilkiinde,  1892.  S.  118. 

^  Vierteljahresschrift  fur  gerichtUche  Medicin,  1893,  S.  55. 

•*  Wiener  klinische  Wochcnschrift^  1890,  No.  9. 


VISCERA!^    CHANGES    LEADING    TO    SUDDEN    DEATH.  149 

the  glottis,  caused  by  the  irritation  of  an  enlarged  or  inflamed  thyroid. 
(Others  claim  to  have  found  softening  and  atrophy  of  the  laryngeal  and 
tracheal  cartilages,  and  believe  that  aspiiyxia  may  result  from  direct 
compression  of  the  trachea  (Rose,  Eppinger,  WolHer).  ]Muller  and 
Ewald  have  not  found  such  changes  in  the  cartilages  and  do  not  regard 
such  a  lesion  as  the  common  condition  in  cases  of  enlarged  thyroid 
resulting  in  sudden  death,  a]»]iarently  excluding  from  this  category  the 
well-recognized  examples  of  tracheal  stenosis  due  to  tumors  of  the 
thvroid.  Kronlein  believes  that  the  contraction  of  the  cervical  muscles 
mav  give  a  fatal  addition  to  the  pressure  ordinarily  exerted  upon  the 
trachea  bv  an  enlarged  thvroid. 

It  appears  from  the  study  of  Ewald  '  that  when  sudden  death  results 
from  enlargement  of  the  thyroid,  this  gland  will  usually  be  found  closely 
bound  to  the  trachea  by  new  connective  tissue.  This  condition,  which 
has  long  been  knoAvn  as  of  rather  frequent  occurrence,  is  referred  by 
Paltauf-  to  an  inflammatory  process,  and  by  Ewald  and  others  to  an 
inward  growth  of  al)errant  masses  of  glandular  tissue  which  have  been 
found  even  projecting  within  the  larynx  and  trachea.  In  such  cases 
the  veins  of  the  thyroid  have  been  found  dilated  and  tortuous,  owing  to 
constriction  by  the  new  tissue,  and  the  larynx  and  trachea  have  been 
f  )und  asymmetrically  compressed.  When  such  a  condition  has  been 
established,  any  cause  leading  to  marked  acute  hyperemia  or  venous 
congestion  of  the  thyroid  may  readily  produce  complete  stenosis  of  the 
larvux  or  trachea  and  sudden  death.  Among  such  causes  mav  be  men- 
tioned  pregnancy,  muscular  exertion,  mental  emotion,  and  acute  inflam- 
mation of  the  larynx,  trachea,  or  enlarged  thyroid. 

Diseases  of  the  lungs,  which  ordinarily  are  attended  with  pro- 
nounced sym})toms,  have  been  found  the  basis  of  sudden  and  unex- 
pected deatli.  The  prostration  which  usually  marks  the  onset  of  lobar 
pneumonia  may  be  successfully  supported  or  even  little  noticed,  espe- 
cially by  homeless  tramps  in  large  cities,  until  the  sufferer  drops  dead 
in  the  street.  In  AVestcott's  series  of  cases  this  fact  was  so  apparent 
as  to  call  for  special  remark  on  the  freciucncy  of  this  lesion  in  bodies 
"  found  dead  "  and  coming  under  the  charge  of  city  autliorities.  The 
<langer  of  sudden  heart  failure  at  all  stages  of  this  disease,  and  even 
during::  convalescence,  is  a  matter  of  rather  common  demonstration  in 
hospitals  wliere  patients  are  carefully  watched  throughout  the  course  of 
the  malady.  Syncope  alone  may  account  for  such  deaths,  or  throm- 
bosis of  the  lieart  and  pulmonary  vessels  may  be  found  at  autopsy. 
Rarely  the  disease  is  fatal  within  a  few  hours  of  its  onset,  from  the 
large  extent  of  the  lesion,  from  congestion  and  edema  of  the  lungs,  or 
from  other  unusual  complications. 

Pulmonary  tuberculosis  terminates  suddenly,  when  the  patient  has 
retained  a  moderate  degree  of  strengtli,  from  a  variety  of  complications. 
Most  frequently  the  rupture  of  a  large  eroded  blood-vessel  causes  sud- 
den fiital  hemoptysis,  or  the  escaping  blood  from  a  smaller  vessel  may 

1   Vierteljahi'esschrift  fiir  gerichtliche  Medicin,  Sup.,  1894,  S.  33. 
^  Ziegler^s  Beitrdge,  1892,  S.  71. 


150  SUDDEN    DEATH. 

be  swallowed  and  the  hemorrhage  be  concealed.  The  formation  of  pyo- 
pneumothorax may  be  very  rapidly  fatal,  or  edema  of  the  active  lung 
or  acute  heart  failure  may  terminate  the  disease  at  a  time  when  the 
dangerous  condition  was  not  fully  recognized.  Tuberculous  myocar- 
ditis associated  with  a  moderate  or  extensive  pulmonary  lesion  may  be 
a  suddenly  fatal  comjilieation. 

Acute  puhnonary  edema  arising  in  the  course  of  chronic  nephritis  or 
arteriosclerosis  is  usually  of  sudden  onset  and  may  be  rapidly  fatal. 
The  condition  of  the  pulmonary  parenchyma  and  the  filling  of  the 
bronchi  with  frothy,  blood-stained  serum  are  characteristic  postmortem 
indications  of  death  from  this  cause.  Fatal  hemoptysis  may  result  from 
other  causes  than  tuberculosis  of  the  lungs,  the  rupture  of  aoi'tic  aneur- 
ysms being  the  most  frequent  origin  of  profuse  hemorrhage  from  the 
lungs  not  referable  to  phthisis.  The  writer  has  the  records  of  a  case  in 
which  the  patient,  otherwise  in  fair  health,  died  almost  instantly  from 
a  profuse  hemoptysis  of  which  no  other  explanation  appeared  than  that 
of  hemophilia.  At  the  autopsy,  the  bronchi,  from  which  the  liemor- 
rhage  originated,  were  filled  with  blood  down  to  their  minutest  l)ranches, 
and  their  walls  congested.  Aside  from  a  little  asjiirated  blood  in  the 
air-vesicles,  the  pulmonary  parenchyma  appeared  normal.  This  patient 
had  had  a  similar  very  severe  hemo})tysis  ten  years  before,  but  her 
family  history  failed  to  show  that  any  relatives  suti^'ered  from  the  hem- 
orrhagic diathesis. 

Acute  bronchitis  involving  the  finer  bronchioles  and  often  compli- 
cated by  bronchopneumonia  sometimes  leads  to  very  rajiid  suffocation. 
Many  sudden  deaths  in  infants  and  the  aged  are  referable  to  this  cause, 
and  Brouardel  refers  to  similar  conditions  occurring  in  adults. 

Of  diseases  of  the  pleura,  large  serous  effusions  have  at  times 
proved  suddenly  fatal,  through  pressure  on  the  heart  and  large  blood- 
vessels or  by  direct  interference  with  respiration.  These  effusions  may 
be  very  rapidly  firmed,  but  more  frequently  the  sudden  fatality  results 
from  a  gradually  accumulated  exudate,  which  has  existed  for  some 
weeks  with  increasing  dyspnea. 

Chronic  diffuse  nephritis  is,  among  organic  diseases,  one  of  those 
most  frequently  leading  to  unexpected  death.  When  the  lesion  takes 
the  form  of  the  "  contracted  kidney,"  a  sudden  termination  without 
previous  marked  symptoms  is  so  frequent  that  medical  writers  com- 
monly describe  certain  groups  of  cases  in  which  sudden  death  without 
premonitory  symptoms  is  the  usual  course  of  the  disease.  As  a  rule, 
sudden  death  occurs  in  these  cases  during  an  attack  of  acute  uremia 
with  general  contraction  of  the  arteries.  When  ne]>hritis  is  followed 
by  or  associated  with  arteriosclerosis,  the  conditions  are  especially  fiivor- 
able  for  a  sudden  termination  by  rupture  of  diseased  blood-vessels.  Even 
without  im])ortant  lesion  in  the  vessel-walls  the  increased  arterial  tension 
and  overaction  of  the  heart,  in  chronic  nephritis,  may  lead  to  rupture  of 
the  thin  cerebral  arteries,  or  even  of  the  aorta. 

It  has  already  been  noted  that  cerebral  hemorrhage  is  immediately 


VISCERAL    CnANGES    LEADING    TO    SUDDEN    DEATH.  151 

fatal  only  in  a  niiiiority  of  the  cases,  as  wLeu  the  lebiuu  is  of  very 
wide  extent  or  affects  a  vital  center. 

Chronic  diffuse  nephritis  may  also  terminate  suddenly  with  severe 
bronchial  dyspnea  and  pulmonary  edema,  or  witli  intestinal  symptoms 
resemhiiuLi'  cholci'a. 

The  liver  is  not  often  the  seat  of  lesions  leading  to  unex[)ected 
death.  The  rupture  of  abscesses  or  cysts  may  be  rapidly  fatal  from 
shock,  liemorrhaij:e,  and  ])eritonitis,  but  such  lesions  have  usually 
])r<istrated  the  patient  before  the  onset  of  the  fatal  com})lication. 
Biliarv  colic  in  rare  instances  has  proved  rapidly  fita!,  even  without 
complications. 

The  stomach  may  be  the  seat  of  sudden  fatal  hemorrhag-e,  due  to 
ulcer,  cancer,  or  chronic  congestion  fi'om  cirrhosis  of  tiie  liver.  The 
rupture  of  a  gastric  ulcer  into  the  peritoneum  is  not  infrequently  fatal 
within  a  few  hours.  Ulcer  of  the  duodenum,  as  a  rule,  gives 
fewer  premonitory  symptoms  than  ulcer  of  the  stomach,  and  in  a  larger 
percentage  of  cases  leads  to  unexpected  death  from  perforation  or  hem- 
orrhage. Brouardel  describes,  under  the  term  <*  dyspeptic  COma," 
some  sudden  fatalities  in  which  the  autopsy  revealed  chronic  constipa- 
tion or  partial  intestinal  obstruction,  but  admits  that  these  cases  are  of 
very  infrequent  occurrence. 

Acute  hemorrhagic  pancreatitis,  on  account  of  the  obscurity 
of  the  sym})toms  and  the  usual  rapidity  of  its  course,  has  attracted  con- 
siderable medicolegal  interest  as  a  cause  of  sudden  death.  A  very 
complete  presentation  of  this  subject  is  contributed  by  Fitz  ^  in  the 
Middleton-Goldsmith  Lecture  for  1889.  As  shown  by  Fitz,  the  fre- 
quency and  importance  of  jiancreatic  hemorrhage  as  a  cause  of  sudden 
death  is  of  recent  recognition,  the  earliest  reported  cases  being  those 
of  Spiess  (1867)  and  Klebs  (1870).  In  1874  Zenker-  reported  2 
cases  of  sudden  death  from  pancreatic  hemorrhage,  and  having  found 
marked  venous  congestion  of  the  solar  plexus  and  abdominal  organs, 
he  attributed  the  deaths  to  shock  and  cardiac  paralysis.  Since  that  time 
other  cases  have  been  accumulated  by  Kollman,  Dra]:)er,  Fit/,  and 
others,  so  that  the  tables  of  Fitz  comprise  Ki  well-authenticated 
instances  of  sudden  death  referable  to  no  other  lesion  than  ])ancreatic 
hemorrhage.  It  appears  from  these  cases  that  fatal  hemorrliage  may 
occur  in  a  previously  diseased  pancreas  or  when  the  individual  is 
apparently  in  sound  health,  and  the  pancreas  otherwise  entirely  fi'ee 
from  evidence  of  disease.  Predisposing  and  exciting  causes  cannot  be 
definitely  stated,  although  the  majority  of  cases  occurred  in  compara- 
tively fat  individuals,  and  traumatism  and  intenqicrance  were  noted  in 
others.  The  onset  of  the  hemorrhage  was  invariably  attended  by 
immediate  prostration  or  collapse,  and  death  ensued  in  from  one-half  to 
thirty-six  hours.  At  the  postmortem  the  j)ancreas  is  found  infiltrated 
w^ith  fresh  blood,  either  wholly  or  in  ]>art,  and  diffusely  throughout  the 
connective    tissue   or   in    circumscribed    areas.       The   infiltration    with 

^  See  Pmceed'mqH  of  the  'New  York  Paiholofikal  Snrieiy,  1889. 
^  DeutHche  Archil- fill-  klinische  Medlcin,  Bd.  ii.,  S.  35L 


152  SUDDEN    DEATH. 

blood  may  involve  the  subperitoneal  tissue  about  the  pancreas,  or 
extend  into  the  omentum,  mesentery,  behind  the  colon,  or  into  the  peri- 
nephritic  fat,  wliile  the  pancreatic  tissue  is  either  normal  or  in  a  con- 
dition of  fatty  infiltration  or  degeneration.  The  exact  origin  of  the 
hemorrhage  has  not  been  demonstrated,  but  from  its  rapidity  and  extent 
Fitz  believes  it  to  be  arterial  rather  than  venous,  and  denies  that  it 
results  from  ruptured  aneurysms  or  fat-necrosis.  Seitz,^  however, 
reports  a  case  of  suddenly  fatal  pancreatic  hemorrhage  resulting  from 
syphilitic  changes  in  the  vessels  of  this  organ. 

Previous  to  publication  of  the  abundant  proof  reviewed  in  the 
article  of  Fitz  it  was  not  universally  recognized  that  pancreatic  hemor- 
rhage must  be  admitted  as  a  cause  of  sudden  death.  Dietrich  ^  con- 
cludes the  report  of  a  fatal  case  of  hemorrhagic  pancreatitis  with  the 
0})inion  that  the  importance  of  pancreatic  hemorrhage  as  a  cause  of 
sudden  death  is  still  hypothetic  and  of  little  consequence  to  the  medical 
jurist.  This  statement  well  represents  the  old  skepticism  on  the  sub- 
ject, and  the  writer  was  probably  not  familiar  with  the  evidence 
collected  by  Fitz.  Of  greater  value  is  the  report  of  Reibold^  of 
pancreatic  hemorrhage  in  ll  cases  of  death  frcMu  other  causes,  one,  a  fat 
woman,  thirty-four  years  old,  dying  from  morphinism  ;  another,  a  man 
of  fifty  years,  who  suicided  by  hanging ;  and  a  third,  a  man  of  thirty- 
five  years,  dying  from  hemorrhage  in  another  locality.  Reibold  con- 
cludes that  pancreatic  hemorrhage  is  merely  a  sign  of  disturbed  circula- 
tion, a  conclusion  that  was  doubtless  correct  in  his  3  cases.  The  con- 
clusions of  Fitz  have  been  amply  supported  by  several  later  studies,  and 
it  may  safely  be  held  that  pancreatic  hemorrhage  may  stand  alone  as  a 
cause  of  sudden  death.  The  exact  origin  of  the  hemorrhage  and  the 
consequence  of  events  which  leads  to  the  fatal  issue  in  these  cases  are 
still  largely  undetermined.  Of  17  cases  of  acute  hemorrhagic  pan- 
creatitis collected  by  the  same  author,  it  appears  tliat  when  hemorrhage 
results  from  acute  inflammation  of  the  pancreas  death  is  not  usually  so 
sudden  as  to  excite  surprise,  for  in  these  cases  pronounced  symptoms 
marked  the  course  of  the  disease  for  at  least  three  days.  A  more 
rapidly  fatal  case  of  this  disease  has  since  been  reported  in  at  least  2 
instances  (Sticker,  Kraft  ■*),  in  which  very  sudden  death  resulted  from 
acute  hemorrhagic  pancreatitis. 

The  Spleen,  when  greatly  swollen,  may  rupture  spontaneously  or  from 
slight  traumatism,  and  sudden  death  may  follow  from  shock  and  hemor- 
rhage, but  such  accidents  usually  occur  in  the  course  of  severe  infectious 
disease  and,  except  in  pernicious  malaria,  do  not  become  of  medicolegal 
interest.  Zenker^  records  a  case  of  sudden  death  from  spontaneous 
hemorrhage  at  the  hilus  of  the  spleen. 

Aside  from  profuse  hemorrhage  arising  from  various  causes,  lemons 
of  the  intestines  rarely  prove  immediately  fatal.     Extensive  strangulation 

1  ZeiUrhrvfi  fiir  klinische  Medicin.  1892,  S.  1. 

^  Vierteljahrenfichrift  fur  qerichtUche  Mrdicin,  Bd.  lii.,  S.  43. 

=»  Virchmv'sJa/n-esherichi,  1887,  Bd.  i.,  S.  508. 

*Ibid.,  1894,  Bd.  ii.,  S.  22-5. 

*  Deutsche  Archiv fur practische  Medicin,  1874,  Bd.  ii.,  S.  351. 


VISCERAL    CHANGES    LEADING    TO    SUDDEN    DEATH.  153 

of  the  intestine  hy  volvulus,  hands,  or  hernia  may,  however,  cause  death 
within  a  few  hours. 

Diseases  of  the  nervous  system  are  rather  less  frequent  causes 
of  sudden  deatii  than  ai'c  ati'ections  of  either  the  respiratory  or  the  cir- 
culatory system. 

Apoplexy,  in  its  most  usual  forms,  has  boon  consid(Mvd  in  connec- 
tion with  the  blo< id-vessels.  Chronic  hemorrhagic  pachymeningitis 
may  terminate  in  an  extensive  hemorrhage  wliich  ])rovcs  suddenly  liital 
after  one  of  the  periods  of  temporary  improvement,  and  in  a  case 
recently  referred  to  hv  the  writer  this  maladv  caused  a  sudden  and 
unexpected  death,  with  sym])toms  of  headache,  coma,  and  collapse,  hut 
without  hemorrhage.  Acute  purulent  meningitis  is  occasionally  fatal 
in  children  or  adults  during  the  first  lew  hours  of  the  violent  onset  that 
usually  characterizes  epidemics  of  this  disease,  and  in  some  cases  even 
without  any  previous  marked  symptoms. 

Of  the  various  diseases  terminating  in  sudden  convulsions  and  coma, 
some  are  directly  referable  to  the  hrain  and  nervous  system.  Epileptic 
convulsions  are  usually  survived,  l)ut  death  results  after  repeated  seiz- 
ures from  cardiac  fiilure,  from  accidental  traumatism,  or,  occasionally, 
from  attacks  of  grand  mal. 

Acute  uremic  or  diabetic  coma  is  often  followed  by  death,  and 
while  the  former  commonly  occurs  without  marked  premonition,  the 
latter  is  rare  except  in  advanced  stages  of  the  disease. 

Acute  alcoholism,  proving  fatal  shortly  after  the  ingestion  of  a 
large  amount  of  liqu(ir  or  terminating  suddenly  after  prolonged  exces- 
sive indulgence  is  responsible  for  a  considerable  number  of  sudden 
deaths  coming  under  the  notice  of  municipal  authorities.  Of  Westcott's 
303  entirely  unexpected  deaths,  29  per  cent,  ^vere  due  to  the  abuse  of 
alcohol.  The  usual  history  of  these  cases  is  that  the  subjects  were 
found  dead  after  a  night's  debauch,  or  that  they  died  soon  after  a  few 
violent  convulsions — "  rum  epilepsy  " — which  terminated  a  more  ]iro- 
longed  spree.  The  postmortem  usually  discloses  one  or  all  of  three 
gross  conditions — the  presence  oi'  alcohol  in  the  stomach,  acute  conges- 
tion of  the  gastro-intestinal  tract,  and  changes  in  the  viscera  resulting 
from  chronic  alcoholism.  These  cases  are  invariably  characterized  by 
deep  coma,  and  death  is  to  be  attributed  to  an  acute  toxemia  princii)ally 
affecting  the  nervous  system.  Chronic  alcoholism  may  end  in 
sudden  deatli  through  the  changes  it  produces  in  the  viscera,  esj)ecially 
in  the  heart  and  blood-vessels,  and  it  is  a  very  general  predisposing 
cause  of  many  other  forms  of  sudden  death. 

The  acute  infectious  diseases,  in  their  malignant  forms,  may 
prove  very  rapidly  fatal.  Lobar  pneumonia  an<l  cerebrospinal  men- 
ingitis furnish  frequent  exam])les  of  this  sort.  In  ej)idemics  of  Asiatic 
cholera,  the  stage  of  collapse  and  death  may  apjx'ar  in  a  few  hours 
from  the  onset,  and  rarely  cholera  morbus  is  fatal  when  it  attacks 
aged  or  enfeebled  individuals  or  infants.  Sudden  deaths  from  yellow 
fever  and  pernicious  malaria  are  not  seen  in  northern  latitudes,  but 
are  not  unknown  in  trojjical  regions. 


154  SUDDEX    DEATH. 

Certain  general  etiologic  factors  are  recognized  as  affecting 
the  frequency  of  sudden  deaths  from  natural  causes.  Persons  of 
advanced  age  are  more  liable  to  sudden  death  than  the  young.  In 
children  the  usual  order  is  reversed,  and  sudden  deaths  are  more  fre- 
quently due  to  asphyxia  than  to  heart  failure.  Cold  weather  favors 
the  occurrence  of  sudden  deaths,  but  certainly  much  less  than  does  the 
excessively  hot  weather  of  the  American  summer.  During  the  severe 
hot  weather  of  August  8th  to  loth,  1896,  there  were  in  New  York  city 
651  deaths  from  sunstroke,  and  the  number  of  sudden  deaths  from 
unknown  causes  was  enormously  increased.  Sudden  changes  of  tem- 
perature and  of  barometric  pressure  also  increase  the  number  of  sudden 
deaths. 

PRESUMPTION  OF  DEATH. 

It  is  contrary  to  the  tendency  of  modern  law  that  the  courts  should 
recognize  any  presumption  in  matters  of  fact  which,  if  the  facts  were 
known,  could  be  determined  with  certainty.  This  principle  is  more 
strictly  followed  at  the  present  day  in  questions  of  survivorship,  in 
which  it  is  generally  held  in  England  and  America  that  in  the  absence 
of  proof  as  to  M'hich  of  two  persons  died  first  when  both  perish  in  the 
same  catastrophe  the  law  can  recognize  no  general  presumption  as  to 
W'hich  of  the  two  may  be  regarded  as  the  survivor.  The  legal  death 
of  persons  long  absent  and  unheard  of,  but  not  proved  to  be  dead,  is, 
however,  presumed  by  courts  of  law  after  the  period  of  seven  years. 

In  such  cases  there  may  be  no  evidence  of  death  other  than  the 
prolonged  and  inexplicable  absence  of  the  individual.  At  other  times 
the  evidence  may  be  very  strong  that  the  person  in  question  has  per- 
ished, as  when  the  ship  on  which  he  is  known  to  have  sailed  has  never 
been  heard  of  or  has  been  shown  to  have  been  Avrecked.  Here,  in  the 
absence  of  full  legal  evidence  of  death  and  of  all  traces  of  a  dead  body, 
the  law  may  presume  the  fact  of  death  long  before  the  usual  period  of 
seven  years  has  elapsed.  In  the  presence  of  such  evidence,  also, 
insurance  companies  usually  settle  claims  at  the  expiration  of  one  or 
two  years.  The  direct  proof  of  death  in  these  cases  is,  therefore,  not 
required,  but  the  law  assumes  that  the  logical  presumption  of  death  is 
sufficient. 

Further,  it  becomes  necessary  fully  to  establish  the  fact  of  the  life 
of  such  persons  supposed  to  be  dead  in  order  to  secure  a  conviction  for 
alleged  bigamy  or  other  crimes.  It  has  been  ruled  by  English  courts 
that  a  wife  mav  lea-allv  marry  arain  after  some  years  of  absence  of  her 
husband,  even  though  she  has  not  made  proper  attempts  to  learn 
whether  or  not  her  husband  is  still  alive,  the  presumption  of  the  laAv 
in  favor  of  the  death  of  persons  long  absent  being  very  strong.  Ameri- 
can courts  are  inclined,  however,  to  require  that  reasonable  searcli  for 
the  absent  party  must  be  made,  what  constitutes  "  reasonable  search  " 
being  a  mixed  question  of  fact  and  law.^ 

The  ordinary  presumption  of  death  may  be  strengthened  by  other  jit'e- 
1  Clark  vs.  Owens,  18,  IST.  Y.,  434. 


PRESUMPTION    OF    SUKVIVOKSHIP.  155 

sumptive  evidence,  such  as  threats  of  suicide.'  Or,  the  presumption  of 
death  inav'  he  set  aside  ])V  confficfliu/  prc.sinnjjfioiis,  and  even  by  hearsay 
and  other  classes  of  evidence  not  onhnarily  achnitted  by  tlie  courts,  the 
tendencv  justly  being  to  recog-nize  every  trace  of  fact  rather  than  rest 
upon  presumption.  There  could  be  no  reasonable  })resumption  of 
death,  for  example,  if  the  person  had  absented  himself  ihv  years  after 
the  commission  of  some  crime. 

When  a  decision  rests  upon  the  life  or  death  of  a  ])erson  at  some 
particular  period  of  seven  year^,  the  presumption  of  the  law  does  not 
cover  the  point,  and  fiu'ther  evidence  as  to  the  time  of  death  is 
required.  In  such  cases  medical  evidence  may  pidve  of  decisive 
iiujiort,  indicating  the  state  of  the  individual's  health  when  last  seen. 
Here,  also,  a  consideration  of  many  of  the  questions  mentioned  as 
affecting  the  presumption  of  survivorship  may  be  involved.  An 
applicable  illustration  referred  to  by  Tidy  ^  is  the  case  of  the  Beasney 
trusts  :  "A  person  who  was  entitled  to  the  dividends  on  stock  payable 
in  April  and  October  a})p]ied  for  his  dividends  in  April.  He  was  last 
seen  in  August  of  the  same  vear,  when  he  was  in  a  verv  bad  state  of 
health.  He  never  applied  for  his  half-yearly  dividends  in  the  ensuing 
October.  It  appeared  that  he  was  of  dissolute  haliits,  and  depended 
chiefly  on  the  dividends  for  his  maintenance.  The  question  in  the 
case  was  whether  he  died  before  Xovember  of  that  year.  It  was  held 
that  not  having  applied  for  the  October  dividend,  and  in  consideration 
of  the  state  of  his  health  when  last  seen,  the  presumption  nuist  be  that 
he  died  before  Xovember." 

By  section  1582  of  the  New  York  Code  it  was  ruled  that  when 
property  was  bequeathed  to  unknown  heirs,  these  heirs  were  presumed 
to  be  dead  after  the  lapse  of  twenty-five  years.  In  the  case  of  People 
ex  rel.  vs.  Ryder  ^  this  legislation  was  declared  unconstitutional,  and 
there  is  at  present  no  presunq)tion  of  death  in  such  cases. 

PRESUMPTION  OF  SURVIVORSHIP. 

At  all  times  it  has  been  found  a  diflicult  and  important  matter  to 
decide  which  of  two  or  more  persons  must  be  regarded  as  the  survivor 
when  all  perish  in  a  common  accident,  such  decisions  not  infrequently 
transferring  large  portions  from  one  heir  to  another. 

It  is  at  once  evident  that  the  decision  shoidd  be  determined  strictly 
by  tlie  facts  of  the  case,  for  it  can  hardly  be  sup]iosed  that  the  deaths 
of  two  or  more  persons  in  the  same  catastroj)he  are  exactly  sinudta- 
neous,  while  the  difference  in  the  time  of  death,  however  slight  it  may 
be,  constitutes  a  real  distinction.  Yet  the  great  variety  of  circum- 
stances surrounding  fatal  accidents  on  sea  and  land  and  the  usual  lack 
of  direct  evidence  as  to  the  fate  of  the  victims  are  usually  insurmount- 
able obstacles  in  the  way  of  ascertaining  these  facts.  Accordingly,  the 
attitude  of  the  law  among  civilized  nations  in  treating  the  question  of 

1  Sheldon  vs.  Ferris,  45  Barb.,  124,  X.  Y.  *  Loc.  cit. 

3  6.5  Hun.,  175. 


156  SUDDEN    DEATH. 

survivorship  has  been  determined  partly  by  ideas  of  expediency  and 
partly  by  consideration  of  the  probable  course  of  events. 

The  old  Roman  law  recognized  general  expediency,  and  to  some 
extent  the  existing  physical  conditions,  by  holding  that  in  the  absence 
of  proof  as  to  which  of  two  persons  died  first,  a  child  above  the  age  of 
puberty  must  be  considered  to  survive  a  parent,  while  parents  were  held 
to  survive  children  under  puberty,  and  the  husband  was  presumed  to 
survive  the  wife. 

The  French  law  as  embodied  in  the  Code  Napoleon  is  based  entirely 
upon  a  consideration  of  the  physical  conditions,  but  recognizing  the 
impossibility  of  determining  the  actual  sequence  of  deaths,  in  the  absence 
of  proof,  adopted  as  a  fixed  rule  the  probable  sequence  as  shown  by  the 
age,  sex,  and  strength  of  the  victims.  If  those  who  perished  together 
were  under  fifteen  years  of  age,  the  oldest  is  presumed  the  survivor. 
If  they  were  all  above  sixty  years  of  age,  the  youngest  is  presumed  the 
survivor.  If  some  were  under  fifteen  and  others  above  sixty,  the 
former  are  presumed  the  survivors.  If  the  ages  of  all  were  between 
fifteen  and  sixty  years,  the  males  are  presumed  the  survivors  if  the 
ages  are  equal  or  the  difference  does  not  exceed  one  year,  and  if  they 
are  all  of  the  same  sex,  the  younger  are  presumed  to  survive  the  older 
persons. 

A  chief  objection  to  the  Napoleonic  code  is  the  extreme  presumption 
in  fiivor  of  infants,  who  may  be  held  to  survive  men  of  sixty-one  years 
of  age,  which  in  fact  they  must  very  seldom  be  able  to  do  when  exposed 
to  the  same  physical  conditions.  Nor  can  either  expediency  or  the 
probable  facts  be  urged  in  favor  of  the  presumption  that  a  youth  of 
fifteen  must  be  considered  the  survivor  of  a  man  of  forty.  To  a  con- 
siderable extent,  however,  the  presum])tions  of  the  French  code  repre- 
sent the  probable  sequence  of  deaths  if  a  number  of  persons  of  all  ages 
and  sexes  were  precipitated  simultaneously  into  the  water. 

The  Prussian  law  is  similar  in  spirit  with  the  Napoleonic  code. 
The  Mahometan  law  of  India  ignores  the  whole  difficulty  by  ruling 
that  when  relatives  perish  together  in  the  same  accident  they  must  all 
be  presumed  to  die  at  the  same  moment.  In  England  and  in  most 
States  of  America  courts  have  held  that  survivorship  must  be  deter- 
mined solely  u]X)n  the  evidence,  in  the  absence  of  which  there  can  be  no 
presumption  of  the  law  in  favor  of  any  age  or  sex.  In  Louisiana, 
which  was  long  under  French  rule,  the  Napoleonic  code  has  been  incor- 
porated in  the  State  laws. 

Not  only  is  there  no  presumption  in  favor  of  age  or  sex,  but  the 
courts  have  ignored  some  very  strong  presumjitive  evidence  based  upon 
the  physical  condition  of  the  victims. 

In  the  well-known  case  of  Wife  ?•-•*.  Angrave,^  husband  and  wife  and 
children  were  swept  by  one  wave  from  the  deck  of  a  vessel  and  dis- 
appeared. It  was  shown  that  the  husband  was  a  powerful  swimmer, 
while  the  wife  was  a  delicate  woman  and  could  not  swim.  Yet  the 
House  of  Lords  would  not  presume  that  one  survived  the  other.     The 

1  8,  H.  of  L.  cases,  213. 


PRE8UMPTIOX    OF    SUKVIVORSHIP.  lo7 

greater  and  decisive  value  placed  upon  very  slight  objective  evidence  is 
seen  in  the  ease  of  Pell  r.s.  l>all.'  Jiall,  his  wife,  aud  daughter  were 
lost  in  an  explosion  on  Ijoard  tiie  steamer  Palnsl;}.  Tlie  wife  was  seen 
after  the  explosion  rushing  about  the  deck  and  calling  for  her  husband, 
who  failed  to  re})ly.  She  was  soon  lost  with  the  sinking  vessel.  The 
fact  that  the  wife  was  seen  alive  after  the  explosion  while  the  husband 
failed  to  appear  or  answer  his  wife's  calls  was  sutlicicnt  evidence  to 
establish  tiie  survivorship  of  the  wife.  Distinctly  contrary  to  the  spirit 
of  these  decisions  is  the  ruling  in  Chancery  in  the  more  recent  case  of 
Seelich  vs.  Bootii,-  in  wliich,  of  two  hrothers,  one,  the  elder  and  master 
of  a  ship,  the  other,  younger,  and  mate  of  the  shij),  both  perishing  in  a 
wTeck,  it  was  held  that  the  younger  died  first. 

It  appears  that  the  province  of  medical  testimony  in  er^tablisiiing  a 
presumption  of  survivorship  is,  in  the  opinion  of  the  courts,  rather 
limited.  While  it  is  probable  that  careful  study  ol"  the  circumstances 
connected  with  the  fatality  and  of  the  physical  condition  of  the  victims 
will  in  nianv  instances  correctly  determine  the  survivor,  the  law 
hesitates  to  applv  so  general  a  rule  of  prol)al)ility  to  individual  cases. 
Yet  the  medical  testimony  in  such  cases  is  usually  considered  with  care, 
and  its  proper  presentation  involves  the  consideration  of  many  condi- 
tions affecting  the  tenacity  of  life  in  (liferent  individuals. 

Tiie  age  of  the  persons  may  have  important  bearing  on  the  question 
of  survivorship  provided  they  have  been  ex]iosed  to  identical  conditions. 
As  already  shown,  age  was  the  principal  factor  considered  in  the  con- 
struction of  the  Code  Napoleon,  in  w^iich  it  is  held  that  there  is  no 
appreciable  difference  in  the  tenacity  of  life  to  be  expected  in  persons 
between  the  ages  of  fifteen  and  sixty  years.  It  is  perhaps  possible  to 
make  rather  closer  distinctions,  however,  in  the  physical  vigor  of  indi- 
viduals as  affected  by  age. 

Complete  physical  development  is  usually  attained  between  the  ages 
of  twenty-five  and  thirty,  and  continued  until  fifty,  although  failing  in 
many  instances  long  before  that  time.  There  Mill,  therefore,  be  no 
evidence  based  upon  age  ca])able  of  affecting  the  ])resum])tion  of  sur- 
vivorship of  persons  between  these  ages,  nor  can  it  be  claimed  that  in 
the  absence  of  other  influences  there  is  always  a  considerable  difierence 
in  vigor  to  be  found  between  the  extremes  of  puberty  and  adult  life. 
But  there  is  a  very  distinct  prol)ability  that  a  middle-aged  adult  will 
survive  a  child  or  an  aged  person  when  both  are  ex))osed  to  the  same 
violence,  and  there  are  numerous  decisions  that  when  a  ])arent  and 
infant  child  perish  together,  the  presum])tion  of  survivorshij)  is  in  favor 
of  the  parent.  It  is  to  be  considered  that  some  forms  of  violence  are 
more  fatal  at  some  ages  than  at  others.  Children  are  very  susce])tible 
to  the  fatal  effects  of  shock,  hemorrhage,  starvation,  and  of  some  drugs, 
but  rarely  perish  from  sunstroke. 

The  ordinary  presumption  based  upon  age  may  be  (.ntweighed  by 
other  presumptive  evidence.     If  a  father,  mother,  and  child  w  ere  fi)und 

1  1,  Cheves  Ch.  cases,  and  American  Journal  Medical  Sciences,  July,  1845. 
'^  Greenleaf  on  Evidence,  p.  47. 


158  SUDDEN    DEATH. 

murdered,  the  usual  presumption  of  survivorship  would  be  exactly 
reversed  in  order,  owing  to  the  probaljility  that  the  murderer  would 
first  attack  the  stronger  person.  If  serious  wounds  were  found  upon 
the  body  of  the  older  and  stronger  of  two  persons  drowned  at  sea,  or 
if  the  older  were  unable  to  swim  while  the  youn(>:er  was  known  to 
be  a  powerful  swimmer,  the  presumption  of  survivorship  might  be 
reversed. 

Sex  is  of  somewhat  less  importance  as  a  factor  in  survivorship. 
Other  conditions  being  similar,  there  is  an  undoubted  balance  in  favor 
of  the  survival  of  the  male,  when  the  loss  of  life  results  from  the  exhaus- 
tion of  pliysical  strength,  and  safety  depends  upon  exertion  or  agility. 
It  is  probable,  but  not  invariable,  that  men  suffer  less  readily  from 
shock  and  hemorrhage,  and  it  has  been  claimed  that  women  are  superior 
in  passive  endurance. 

The  state  of  health  may  outweigh  the  prcsimiptive  evidence 
given  by  both  age  and  sex.  An  adult  male  invalid  may  reasonably  be 
expected  to  perish  from  any  of  the  usual  forms  of  violence  before  a 
healthy  adult  female  or  child,  and  there  is  abundant  precedent  to  show 
that  such  evidence,  reaching  as  it  does  almost  to  the  grade  of  certainty, 
may  be  expected  strongly  to  influence  the  decision  of  the  court.  If 
may,  therefore,  become  important  to  study  in  sucli  detail  as  the  evidence 
will  permit  the  general  condition  of  health  of  the  persons  concerned. 

The  manner  of  death  and  the  circumstances  surrounding  it 
require  consideration  in  every  attempt  to  establish  doubtful  survivor- 
ship, and  the  evidence  thus  obtained  will  generally  be  found  of  more 
decisive  nature  than  the  consideration  of  age,  sex,  or  state  of  health. 

Asphyxia. — It  is  by  many  regarded  as  an  established  fact  that 
women  resist  death  from  asphyxia  longer  than  men,  as  is  possibly  to  be 
expected  from  the  known  physiologic  rule  that  women  consume  less 
oxygen  than  men.  Partly  on  this  account,  in  eases  of  asphyxia  by 
gases,  the  chances  of  survivorshiji  are  usually  granted  to  favor  the 
woman.  The  observations  on  which  this  opinion  are  chiefly  based  are 
referred  to  by  Guy  and  Ferrier.^  "In  19  of  360  cases  of  poisoning  by 
charcoal  fumes  which  occurred  in  Paris  in  1834—35,  a  man  and  a 
woman  were  exposed  to  these  gases  together.  Of  these,  only  3  were 
saved,  and  these  were  women.  In  the  solitary  cases,  18  of  73  females 
and  19  of  83  males  were  restored,  so  that  the  chances  in  favor  of  the 
female  are  nearly  as  15  to  14.  In  a  case  reported  b}'  W.  Sardaillon,  a 
man,  his  wife,  and  their  child  were  asphyxiated  in  a  porter's  lodge. 
The  child  died,  the  father  was  very  ill  and  with  difficulty  restored  to 
life,  while  his  wife  w^as  able  to  call  for  help  and  assist  both  husband 
and  child."  The  foregoing  evidence  is  interesting  and  valuable,  but 
far  from  conclusive,  for  a  single  series  of  observations  must  be  regarded 
as  entirely  inadequate  to  prove  any  general  rule  relating  to  facts  in 
medicine.  Observations  in  such  cases,  to  be  reliable,  must  include  the 
minutest  details  of  age,  habits,  state  of  health,  and  especially  of  the 
position  of  the  bodies  with  reference  to  possible  sources  of  air. 

1  Principles  of  Forensic  Medicine,  p.  312. 


PRESUMPTION    OF   SURVIVORSHIP.  159 

The  proximity  to  air,  as  well  as  the  relative  exposure  to  injury, 
determines  with  considerahh'  certainty  the  survivors  in  fatal  accidents 
where  bodies  are  piled  one  upon  another,  as  occurs  in  panic-stricken 
crowds  or  in  collapsed  buildinos.  In  disasters  in  mines,  some  bodies 
are  commonlv  found  injured  by  the  explosion  of  firedamj),  others 
suifocated  bv  falling  earth,  still  others  slowly  sufl'ocated  or  exliausted, 
but  Iving  in  a  portion  of  the  mine  less  affected  by  the  ex])losion,  in 
which  case  the  order  of  survivorship  is  clearly  indicated. 

In  death  bv  drowning,  althouuh  men  are  more  likely  to  be  on  the 
deck  of  a  vessel  at  the  time  of  an  accident,  are  more  active  in  avoiding 
danggr,  are  more  often  good  swimmers,  are  less  encumbered  by  clothing, 
and  are  more  self-possessed  in  securing  life-preservers  or  other  floating 
objects,  the  courts  have  repeatedly  refused  to  place  any  great  value 
upon  such  general  presumptive  evidence.  If  the  bodies  are  recovered, 
it  has  been  pointed  out  that  marks  of  severe  injuries  will  weigh  against 
survivorship,  and  evidence  of  an  attempt  to  save  others,  as  shown  by 
the  position  of  two  bodies,  will  tell  in  favor  of  survivorshij). 

Cold. — Men  endure  cold  l)etter  than  women,  and  adults  better  than 
the  aged,  while  young  children  are  least  capable  of  withstanding  its 
effects.  In  general,  the  greater  the  Ixxly-weight,  the  longer  will  the 
body  require  to  cool  and  life  be  retained.  The  amount  of  clothing,  the 
development  of  adipose  tissue,  and  the  state  of  health  considerably  affect 
the  power  of  resistance  against  cold.  The  use  of  alcohol  or  narcotic 
drugfs  markedlv  increases  the  danger  of  death  from  cold,  as  both  reduce 
temperature,  muscular  activity,  and  general  sensibility. 

Heat  is  not  often  concerned  in  questions  of  survivorsliip,  and  little 
is  known  of  the  relative  tolerance  of  the  ages  and  sexes.  Children  do 
not  often  ])erish  from  sunstroke.  In  death  from  burns,  the  ]ihysical 
examination  and  the  position  of  the  bodies  will  dctenuine  as  far  as 
possible  the  survivor.  Children,  being  very  susceptible  to  shock,  early 
succumb  to  the  effects  of  burns. 

Starvation. — Children  are  rapidly  exhausted  by  lack  of  food,  and 
it  is  a  common  observation  that  the  withdrawal  of  f(X)d  for  a  few  hours 
raav  determine  the  death  of  infuits  from  acute  gastro-intestinal  diseases. 
It  iias  been  claimed  that  the  aged  are  more  tolerant  to  lack  of  food  than 
are  adults,  a  claim  that  can  hardly  l)e  supjiorted  unless  the  aged  person 
is  in  a  better  state  of  general  nutrition.  It  would  seem  more  reasonai>le 
and  more  in  accordance  with  the  evidence  furnished  by  clinical  experi- 
ence that  between  adults  and  old  ])ersons  tlie  probability  of  survivorship 
depends  less  upon  the  (piantity  of  f)od  required  at  different  ages  than 
upon  the  state  of  nutrition  and  the  development  of  adipose  tissue. 
From  the  experience  of  professional  fasters  it  is  evident  that  life  may 
be  supported  for  long  periods  without  food,  by  the  u^^c  of  water,  :n)d 
that  the  Avithdrawal  of  both  food  and  water  will  ]u-ove  more  rapidly 
fatal  than  the  lack  of  food  alone. 

Electricity. — The  depth  and  extent  of  burns  upon  the  body,  the 
presence  of  metallic  conductors  of  any  sort  in  the  clothing,^  and  the 
position   of  the  bodies  with  reference  to  the  source  of  electricity  may 


160  SUDDEN    DEATH. 

furnish  indications,  very  obscure  at  best,  of  the  probable  survivor  in 
death  from  this  cause.  The  fatal  eifects  of  lightning  have  beeu  dis- 
tributed in  the  most  irregular  and  inexplicable  manner.  The  instan- 
taneous character  of  the  shock  and  our  lack  of  detailed  knowledge  of 
the  fatal  action  of  electricity  render  the  determination  of  survivorship 
in  deaths  from  this  cause  especially  difficult. 

Parturition. — It  is  probable  that  in  most  cases  of  parturition  end- 
ing fatally  to  mother  and  child,  either  with  or  without  attendance,  the 
child  perishes  before  the  mother,  but  the  conditions  in  the  case  may  dis- 
tinctly indicate  that  the  child  survived  the  mother.  The  fact  that  the 
life  of  the  child  may  continue  in  ufero  is  amply  attested  by  numerous 
successful  postmortem  deliveries.  But  only  children  born  alive  are 
legally  recognized  as  living  beings,  so  that  the  survival  in  utero  need 
not  be  considered.  In  the  absence  of  definite  evidence  that  the  child 
was  still-born  it  would  appear  that  the  usual  facts  are  most  accurately 
met  by  the  decision  of  the  Imperial  Chamber  at  Wetzlar,  quoted  by  Tidy, 
in  favor  of  the  child,  on  the  ground  that  the  mother  sank  exhausted  by 
the  pains  of  labor,  while  the  child  died  subsequently  from  lack  of 
nourishment.  Such  evidence  of  still-birth  may  be  the  maceration  of 
the  skin,  indications  of  prolonged  second  stage,  signs  of  great  com- 
pression or  molding  of  the  head,  a  very  extensive  caput  succedaneum, 
meningeal  hemorrhage,  and  internal  signs  of  death  by  acute  asphyxia, 
with  complete  atelectasis  of  the  lungs.  When  the  mother  dies  of  active 
hemorrhage  after  delivery,  the  chances  are  probably  even  more  favora- 
ble for  the  survival  of  the  child,  which  is  capable  of  existence  for  some 
time  after  detachment  of  the  placenta  from  the  uterus.  Yet  all  these 
considerations  are  usually  outweighed  by  the  ruling  that  the  life  of  the 
child  requires  proof,  while  that  of  the  mother  does  not,  and  decisions 
in  such  cases  are  usually  in  favor  of  the  survival  of  the  mother. 

In  death  from  poisoning,  the  quantity  of  the  drug  ingested,  the  age 
and  physical  condition  of  the  victims,  and  the  influences  of  idiosyncrasy 
should  be  considered. 

The  degree  of  postmortem  changes  may  occasionally  be  worth  con- 
sidering when  bodies  are  seen  shortly  after  death,  but  only  with  the 
cautions  emphasized  in  the  section  on  Signs  of  Death. 

In  general  the  minutest  details  in  regard  to  the  manner  of  death, 
the  position  of  the  bodies,  and  the  results  of  postmortem  examination 
should  be  considered  with  the  usual  expectation  of  reducing,  in  some 
slight  degree  only,  the  presumptive  character  of  the  evidence  relating 
to  survivorship. 


DEATH  FROM  COLD,  HEAT,  AND  STARVATION. 


DEATH  FROM  COLD  AND   HEAT. 

Physiologic  Considerations. — Both  cold  and  heat  are  capable 
of  inducini;'  fatal  effects  when  aj)j)licd  to  the  animal  hodv,  and  lor  the 
most  part  the  mode  of  action  is  the  same  in  each  case.  The  deleterious 
influences  may  be  regarded  as  ])artly  exerted  upon  the  vascular  appa- 
ratus and  circulatory  function,  and  jiartly  as  due  to  the  action  of  toxic 
principles  generated  within  the  body  imder  the  circuinstauces  of  its 
abnormal  environment. 

It  cannot  be  stated  distinctly  how  these  vascular  influences  are 
induced,  but  it  is  safe  to  say  that  circulatory  faults  may  be  produced  in 
either  case  in  part  directly,  partly  thi'ougli  nervous  reflexes,  and  partly 
by  the  toxins  just  mentioned.  These  toxins,  of  M'hose  actual  nature 
definite  information  is  yet  to  be  had,  are  partly  those  which  are  natur- 
ally generated  by  the  animal  body  and  retained  by  reason  of  the 
impotency  of  surface  excretion,  partly  the  result  of  local  degeneration 
of  tissues  influenced  by  the  cold  or  heat,  and  partly  the  result  of  a 
general  functional  derangement  induced  by  the  abnormal  temperatiu*e 
of  the  body  and  vascular  derangements  consequent  to  the  same. 

The  temperature  of  the  human  body  in  health  is  subject  to  variation 
from  the  position  of  thermometric  application,  age,  time  of  day,  condi- 
tion of  bodily  nutrition,  exercise,  personal  peculiarities,  and  other  minor 
factors.  It  is  least  up(m  the  surface  of  the  extremities  (35.3°  C. — 95.5° 
F.),  less  upon  the  open  surface  (35.5°  C — 96°  F.)  than  in  protected 
situations,  as  in  the  axilla  or  perineum  (36.6°-37.1°  C— 98°-98.8°  F.), 
and  highest  in  the  accessible  cavities,  as  the  mouth,  vagina,  or  rectum 
(37°-37.6°  C— 98.3°-99.8°  F.).  At  time  of  birth  the  temperatm-e  of 
the  infant  is  one  or  two  degrees  above  that  of  the  mother,  but  it  falls 
rapidly  to  near  the  average.  In  old  age  again  the  tenijierature  is  apt  to 
be  slightly  above  normal.  It  is  higher  in  the  evening  than  in  the 
early  morning,  the  daily  variation  being  from  one  to  one  and  a  half 
degrees  Fahrenheit  as  an  average.  As  a  rule,  full  bodily  vigor  is  coin- 
cident with  slight  excess  of  bodily  temjierature  over  low  states  of 
nutritional  excellence  ;  and  the  flush  of  bodily  exercise  is  marked  by  a 
slight  rise  of  temperature.  There  are  also  |X'rsons  who  normally  present 
slight  variations  above  or  below  the  average  normal  temjierature  of  the 
axilla  (37°  C— 98.3°  F.). 

Precisely  how  this  normal  temperature  is  produced  and  preserved  is 
not  thoroughly  understood.  Fundamentally  it  is  proljably  the  result 
of  chemical  activities  going  on  in  the  blood,  glands,  muscles,  and,  to  a 

Vol.  I.— 11  161 


162  DEATH    FROM    COLD    AND    HEAT. 

less  extent,  other  parts  of  the  system  ;  these  chemical  changes  being 
mainly  those  of  oxidation,  although  other  and  more  intricate  chemical 
changes  are  nnquestionably  largely  concerned.  This  generation  of  heat 
is  to  a  greater  or  less  degree  regulated  by  a  therniQgenic  mechanism 
situated  in  the  spinal  cord,  medulla,  and  basal  cerebral  ganglia.  Its 
uniformity  is,  moreover,  to  a  large  measure  determined  by  the  rate  of 
thermolysis  or  heat  dissipation.  The  dissipation  of  heat  takes  place 
mainly  from  the  surface  of  the  body  by  radiation,  convection,  and 
absorption  in  the  evaporation  of  the  sweat ;  it  is  also  lost  by  convec- 
tion from  the  lungs  ;  and  there  exist  thermolytic  nervous  centers  in  the 
medulla  and  basal  ganglia,  regulating  in  a  measure  the  activity  of  the 
process.  In  the  rate  of  loss  by  all  these  means  much  depends  upon  the 
temperature  of  the  surrounding  medium,  as  favoring  or  not  one  or  more 
of  the  modes  of  dissipation.  Thus  a  cold  surrounding  atmosphere  per- 
mits the  direct  radiation  of  heat  from  the  body,  gradually  diminishing 
with  rise  of  surrounding  temperature  and  ceasing  when  the  atmospheric 
temperature  approximates  that  of  the  body.  Convection  is  favored  by 
the  coincidence  of  moisture  and  lo\vness  of  temperature  of  the  surround- 
ing atmosphere,  the  cool  particles  of  moisture  abstracting  heat  from  the 
warm  body  to  their  own  evaporation.  JNIotion  of  this  cool  moist  atmos- 
phere augments  its  refrigerating  power  by  constantly  bringing  to  the 
body  surface  fresh,  cold  particles  of  moisture  to  abstract  further  heat. 
Thus  is  explained  the  chilling  power  of  cold  winds  in  moist  climates. 
Convection  is  favored  also  by  a  high  temperature  of  the  surrounding 
atmosphere,  coinciding  with  dryness  of  the  air,  such  a  combination  ])er- 
mitting  free  evaporation  of  the  perspiration  poured  f  )rth  upon  the  skin 
surface,  and  easy  absorption  of  moisture  from  the  lungs  by  the  air 
inhaled.  A  combination  of  such  conditions  prevailing,  comparatively 
high  degrees  of  atmospheric  temperature  may  be  withstood  with  little 
discomfort.  Far  less  animal  heat  is  lost  by  convection  in  a  cold  dry 
air  than  in  a  cold  moist  air  ;  and  a  warm  moist  atmosphere  decidedly 
retards  the  cooling  influence  of  perspiratory  evaporation,  thus  increasing 
the  discomfort  of  warmth  to  the  body.  The  amount  of  air  inspired, 
its  temperature,  and  its  humidity  likewise  influence  in  distinct  measure 
the  rate  of  heat  dissipated  ;  the  amount  and  temperature  of  liquids  and 
solids  ingested,  by  adding  or  abstracting  heat  from  the  body,  must  also 
influence  the  rate  of  heat-loss.  In  addition  to  these  there  probably 
exist  in  the  central  nervous  system,  in  much  the  same  situations  as  the 
heat  generative  centers,  other  centers  which  inhibit  the  production  of 
animal  heat  and  thus  aid  in  maintaining  the  heat  balance  at  a  uniform 
degree.  Further,  as  influencing  most  materially  the  rate  of  heat  dissi- 
pation, the  amount  and  character  of  clothing  must  be  kept  constantly 
in  mind. 

■ 

Influence  of  Cold  and   Heat  applied  to  the  Body  Surface.^For 

the  present  consideration,  by  far  the  most  important  primary  influence  in 
the  production  of  deleterious  effects  is  that  exerted  by  the  temperature 
upon  the  rate  of  heat  dissipation  through  the  skin.  Such  are  brought 
about  mainly  by  modifications  in  the  circulation  of  the  surface.    Increases 


PHYSIOLOGIC    COXSIDERATIOXS.  163 

or  diminutions  of  thcrmogenosis  and  toxic  dcvelopmont  enter  secondarily 
but  probably  in  important  detjrce  in  the  later  manifestations  of  indi- 
vidual cases.  The.  eti'ects  of  local  apj)lication  (»!"  cold  or  heat  to  the 
surface  may  be  taken  as  an  indication  of  the  effects  of  similar  tempera- 
tures generally  applied,  and  may  be  used  in  exj)lanation  of  the  lethal 
effects  produced. 

If  the  hand,  for  example,  is  thrust  into  an  icy  tenijicrature,  the 
primary  result  is  a  stimulation  of  the  j)ilomotor  apparatus,  of  the  mus- 
cular fibers  close  to  the  sin'face,  and  consequently  a  constriction  of  the 
vessels  of  the  skin.  The  surface  becomes  blanched,  the  skin  coni- 
pact,  "  goose-flesh  "  appears,  the  surface  becomes  nmnb  ;  the  blood  is 
driven  from  the  surface  exposed  to  the  cold,  and  to  a  certain  degree  loss 
of  heat  by  absorption  from  the  warm  blood  prevented.  A  longer 
exposure  is  followed  by  a  diffuse  reddening  of  the  exposed  surface,  as 
the  blood  returns  to  the  part  in  increased  amount,  either  as  the  result 
of  a  nervous  reflex,  from  the  stimulation  by  the  cold  leading  to  a  dilata- 
tion of  the  vascular  apparatus  of  the  skin,  or  as  a  direct  i)aralyzant 
result  of  the  cold  upon  the  tissues  and  vessel-walls  of  the  exposed  part. 
Temporarily  this  increase  of  warm  blood  coming  to  the  chilled  surface 
tends  to  preserve  the  temperature  balance  of  its  tissues  and  maintain 
their  intes^ritv  :  but  with  the  continued  and  increased  loss  of  heat  to  the 
external  cold  medium  such  balance  is  eventually  again  destroyed,  and 
the  tissue  elements  altered  to  a  greater  or  less  degree.  If  the  part 
exposed  is  a  dependent  one,  the  blush  thus  induced  advances  in  its 
intensity,  by  a  gratlual  paralysis  of  the  vessel-walls,  to  a  cyanosis  or 
deep  congestion,  with  consequent  tumefaction,  tingling,  and  pain,  or,  in 
advanced  degrees,  actual  anesthesia.  If,  however,  the  surface  is  readily 
drained,  the  blood  again  gradually  recedes  to  the  interior,  to  occupy  the 
larger  vessels  and  capillary  areas  of  the  internal  viscera,  and  the  sur- 
face remains  white  and  the  part  unswollen.  If  attached  to  the  living 
body,  such  a  congested  part  in  its  reaction  becomes  the  seat  of  more  or 
less  intense  inflammation  or  gangrene ;  while  in  case  of  actual  destruc- 
tion of  the  tissue,  in  tlie  severer  forms  of  exposure  to  cold,  the  inflam- 
matory reaction  is  limited  almost  entirely  to  the  area  of  demarcation 
between  the  necrotic  and  the  living  part.  In  case  of  death  by  freezing, 
the  blood,  as  noted  l)y  various  observers,  remains  fluid,  although  alter- 
ations of  a  decisive  character  take  place  in  its  constitution.  These  alter- 
ations of  blood  constitution  j>rol)ably  play  a  distinct  part  in  the  final 
lethal  effect  of  cold  both  nutritively  and  in  the  capacity  of  oxygen  con- 
vection ;  also  in  the  development  of  toxic  materials. 

If  the  entire  body  surface,  including  the  lungs,  instead  of  a  portion, 
is  exposed  to  the  influence  of  long-continued  and  intense  cold,  there  will 
be  noted  as  a  result  contraction  of  the  skin,  blanching  of  the  surface, 
superficial  nmscular  stimulation,  manifested  by  shivering,  and  distinct 
sensati(m  of  cold.  Succeeding  these  the  surface  becomes  reddened,  a 
glow  of  Avarmth  and  a  sensation  of  tingling  or  mild  pain  develoji.  This 
is  especially  true  for  the  extremities,  where  the  circulation  is  not  so 
active  as  in  the  p-eneral  svstem.      It  is  not  known  whether  this  blush  of 


16-4  DEATH  FROM  COLD  A>«D  HEAT. 

the  surface,  secondary  to  the  primary  blanching,  is  due  to  a  direct  or  a 
reflex  influence,  but  it  is  probably  the  resnlt  of  a  paralysis  of  the  vaso- 
constrictor and  muscular  fibers  of  the  skin  in  the  vicinity  of  the  vessels. 
This  vascular  dilatation,  thus  far  noted  only  in  the  vessels  of  the  sur- 
face, gradually  extends,  as  the  influence  of  the  cold  penetrates  more 
deeply,  to  the  larger  vessels  and  viscera  of  the  interior,  Avhich,  in  a 
relaxed  state,  are  competent  to  contain  the  entire  bulk  of  the  blood  of 
the  body.  In  consequence  the  blood  is  withdrawn  from  the  surface  to 
the  interior,  thus  leaving  the  skin  blanched,  and  the  interior  ^  essels, 
including,  those  of  the  brain,  completely  filled.  Such  conditions  are 
found  postmortem.  Other  factors,  however,  are  also  to  be  sought  for 
in  the  production  of  the  cardiac  failure  which  usually  terminates  life, 
since  in  most  instances  the  degree  of  internal  congestion  is  insufficient 
to  account  mechanically  for  the  cessation  of  circulation,  and  to  explain 
other  phenomena  uniformly  found.  An  important  influence  is  probably 
exerted  by  various  poisonous  principles  which  exist  in  the  blood  and 
tissues  in  consequence  of  the  inability  of  the  bloodless  skin  to  perform 
its  usual  excretory  function,  as  well  as  in  consequence  of  distinct  meta- 
bolic changes  in  the  fluids  and  tissues  which  are  under  the  influence  of 
the  cold.  The  importance  of  the  skin  excretion  is  mcII  shown  in  the 
frequently  cpioted  experiment  of  varnishing  the  skin  of  a  lower  animal 
with  an  impervious  covering  to  prevent  the  escape  of  the  excretory  prod- 
ucts. Under  these  circumstances  death  usually  occurs  in  the  course 
of  some  hours,  with  symptoms  of  implication  of  the  nervous  svstem. 
The  fluidity  and  bright-red  color  of  the  blood;  the  heightened  internal 
temperature  of  the  earlier  stages,  indicating  increased  chemical  changes ; 
the  constant  tendency  to  somnolence  and  coma  (jSIosso  has  shown  that 
certain  conditions  of  the  blood  of  fatigued  animals  may,  by  transfusion, 
transmit  the  tendency  to  sleep  to  the  receiving  animal),  all  point  to  the 
development  and  active  participation  of  such  poisonous  substances. 
Their  nature  is,  however,  as  yet  undetermined. 

Compared  with  the  effects  of  cold,  the  action  of  heat  bears  a  marked 
similarity,  differing  only  in  minor  details  of  the  vascular  phenomena. 
Local  exposure  of  the  surface  to  an  intense  heat  causes  at  first  a  l)rief 
period  of  contraction,  which  is  rapidly  followed  by  relaxation.  This 
manifests  itself  by  a  diffuse  blush,  which  may  again,  if  the  blood 
remain  in  the  part,  proceed  to  a  deep  congestion,  inflammation,  and 
gangrene.  This  last,  in  local  bums,  just  as  in  local  freezing,  may  be 
attended  by  formation  of  blisters  or  may  ])roceed  to  a  more  rapid  tissue 
destruction,  as  in  the  production  of  eschars  or  chars.  Applied  more 
slowly  and  in  less  intense  degree,  the  vascular  dilatation  gradually 
extends  to  the  vessels  of  the  interior,  and  the  surface,  if  easily  drained, 
becomes  bloodless.  Thus,  in  the  effect  of  general  exposure  to  heat,  the 
same  phenomena  occur,  the  primary  period  of  blanching  being  of  little 
mark  and  unnoted ;  later  the  surface  becomes  generally  reddened,  and, 
owing  to  the  hyperemia,  the  sweat-glands  become  stimulated  to  profuse 
activity.  The  evaporation  of  perspiration  for  a  time  exerts  a  refrige- 
rant action  and  tends  to  preserve  the  heat  balance,  but  if  evaporation 


DEATH    FROM    COLD.  165 

is  impeded  by  the  humidity  of  the  surrounding  atmosphere,  the  final 
effects  of  the  heat  are  accelerated.  Or,  after  a  time,  from  excessive 
activity,  the  function  of  the  sweat-glands  becomes,  as  it  were,  paralyzed, 
and  the  dilating  influence  of  the  heat  is  felt  more  and  more  centrally. 
The  blood  is  thus  permitted  to  proceed  from  the  surface  of  the  body 
to  the  interior,  and  the  same  train  of  symptoms  is  induced,  with  the 
same  final  consequences  of  circulatory  failure  and  death,  as  in  the  case 
of  application  of  cold.  Here,  also,  probably  the  same  impfirtant  role 
is  played  by  a  number  of  unknown  toxic  principles  arising  within  the 
body,  naturally  or  under  the  inliuence  of  the  heat-exposure,  and  pre- 
vented free  escape  through  the  skin  because  of  the  failure  of  perspira- 
tion. This  additional  feature,  however,  marks  the  develo})meut  of  the 
lethal  effects  of  heat.  The  animal  heat,  increased  as  it  is  by  the 
chemical  activities  leading  to  the  formation  of  toxins  and  under  their 
influence,  as  well  as  through  central  nervous  influence,  failing  of  its 
proportionate  dissipation,  increases  rapidly  and  extremely  in  these  cases 
and  constitutes  one  of  the  most  important  features  of  death  from  heat- 
exposure. 

DEATH  FROM  COLD. 

The  degree  of  cold  required  to  produce  death  must  vary  widely  in 
individual  cases,  depending  upon  the  natural  and  artificial  powers  of  pro- 
duction and  conservation  of  heat  possessed  by  the  individual.  Degrees 
of  temperature  very  insufficient  actually  to  freeze  the  tissues  or  fluids 
of  the  body  may,  under  proper  combination  of  person  and  environment, 
suffice  to  lower  the  body  temperature  enough  to  determine  death.  On 
the  other  hand,  an  individual  in  free  vigor,  with  proper  nutrition  and  a 
sufficiency  of  suitable  clothing,  may  withstand  degrees  of  temperature 
as  extreme  as  —73°  C.  (—94.4°  F.)  with  comparative  impunity,  at  least 
for  a  limited  period  of  time.  Experimental  studies  on  the  subject  have 
shown  that  it  is  impossible  to  fix  a  definite  degree  of  temperature  at 
which  death  wilb  invariably  take  place.  As  in  most  instances  of 
ordinary  illness,  a  depression  of  body  temperature  of  but  a  few  degrees 
(4°  to  10°  F.)  is  regarded  as  more  or  less  prognostic  of  death,  although 
there  are  isolated  instances  in  which  very  much  greater  depressions  have 
been  recovered  from  ;  so,  also,  in  case  of  exposure  to  cold,  while  death 
mav  sometimes  in  the  weak  or  ao;ed  be  induced  bv  refrigeration  to  but 
a  few  degrees  below  normal,  yet  there  are  recorded  instances  of  recovery 
where  the  accessible  cavity  temperature  was  as  low  as  75°  F.  or  lower. 
It  is,  therefore,  impossible  to  predicate  that  death  from  exposure  to  cold 
cannot  take  place  because  the  temperature  of  the  surrounding  atmos- 
phere or  other  medium  is  not  at  or  below  32°  F. 

Infants  and  the  aged  are  particularly  liable  to  the  imtoward  effects 
of  such  exposure,  having  little  reserve  of  thermogenic  ]iower.  Owing 
to  the  low  conductile  influence  of  a  greater  deposit  of  subcutaneous  fat, 
woman  is  able  to  jH'eserve  her  body  temperature  more  readily  than  man, 
and  is,  therefore,  other  things  being  equal,  less  liable  to  death  from  the 
cause  in  question.  This  statement  must  be  accepted,  however,  with 
reservation,  the  modern  protected,  artificial  life  of  females  reversing  in 


166  DEATH    FROM    COLD. 

great  measure  their  natural  advantages.  Persons  of  slight  bodily  vigor, 
persons  of  spare  build,  persons  whose  vitality  has  been  impaired  and 
whose  temperature  balance  is  deranged  by  disease,  or  who  have,  from 
vascular  or  cardiac  disease,  little  circulatory  tone,  as  Mell  as  those  who, 
from  traumatism  or  operation,  have  suffered  from  cardiac  failure, 
collapse,  or  severe  hemorrhage,  are  predisposed  to  the  effects  of  cold 
and  withstand  its  influences  less  strongly  than  normal  individuals. 
Persons  who  eat  but  little  or  mostly  of  vegetable  food  are  less  likely  to 
withstand  refrigeration  than  full  eaters  and  those  who  habitually  eat 
meats  and  fats ;  and  it  is  well  known  that  starvation  and  death  by 
freezing  are  apt  to  be  coincident.  The  popular  use  of  alcohol  to 
sustain  the  body-temperature  during  exposure  is  based  on  fallacious 
ideas,  and  habitual  alcoholism  is  a  very  important  predisposing  cause 
in  the  occurrence  of  death  from  cold.  Alcohol  excites  a  sensation  of 
warmth  by  temporary  stimulation  of  the  circulation,  thus  bringing 
warm  blood  to  the  chilled  surface ;  but  by  thus  aiding  in  heat  dissipa- 
tion it  merely  hastens  the  fatal  result.  Its  only  possible  use  is  a 
temporary  one,  and  it  should  never  be  employed  where  any  but  a 
transient  effect  is  desired.  The  drunken  stupor,  with  its  weakened 
circulation,  is  a  state  especially  fraught  with  danger  in  ease  of  exposure. 
Other  beverages  and  drugs  having  a  temporary  circulatory  stimulative 
power  produce  only  a  false  sense  of  benefit.  Coffee  and  tea  belong  to 
this  category,  although  the  heat  of  the  liquid  in  which  they  are  diffused 
is  here  of  material  value  in  restoring  to  some  extent  the  lost  somatic 
temperature.  So,  also,  drugs  having  a  depressing  effect  upon  the  circu- 
lation favor  the  action  of  cold. 

The  influence  of  clothing  in  the  maintenance  of  the  body  tempera- 
ture is  of  great  importance,  in  that  this  constitutes  the  most  potent  arti- 
ficial factor  available  to  man  to  prevent  heat  dissipation  from  the  sur- 
face. The  main  value  of  clotlies  depends  on  the  amount  of  Avarm  air 
which  they  are  able  to  retain  in  contact  or  close  to  tlie  skin  rather  than 
the  degree  of  warmth  attained  by  their  own  fabric  ;  and  it  thus  follows 
that  a  given  weight  of  material  disposed  so  as  to  maintain  several  layers 
of  warm  air  between  the  skin  and  the  external  cold  is  more  efficient 
than  when  arranged  as  a  single  layer.  In  material,  porosity  and  small 
power  of  hygrosco])y  determine  the  warming  excellence  of  clothing. 
The  air-spaces  of  such  textures  retain  in  a  measure  the  air  warmed  from 
the  body  surface.  The  small  amount  of  moisture  present  prevents  much 
loss  by  absorption  to  the  evaporation  of  the  moisture.  The  color  of  the 
goods  employed  also  exerts  a  slight  influence.  A  light  colored  material 
reflects  most  of  the  warmth  from  the  external  sources  and  is  of  no 
material  advantage  in  lowering  radiation  ;  while  darker  materials  absorb 
heat  from  every  available  external  source  and  liave  little  power  of 
reflection.  For  purposes  of  warmth,  then,  a  number  of  layers  of 
loosely  woven  woolen  garments  of  a  dark  color  stand  first  in  order  of 
efficiency  ;  while  the  closely  woven  white  cotton  or  linen  goods  have 
least  protective  power.  During  sleep,  during  which  period  heat  genesis 
is  decidedly  low  and  heat  dissij^ation  free,  the  amount  of  clothing  should 


SYMPTOMS.  1G7 

be  greater  than  during  the  moments  of  wakeful  activity — perhaps  one- 
third  more  clothing  being  desirable  during  slumber  than  wiien  tiie  indi- 
vidual is  awake.  It  is  of  interest,  finally,  to  note,  in  cases  exposed  to 
cold,  tiiat  the  posture  of  the  body  will,  to  a  certain  extent,  determine 
the  rate  of  heat  loss  ;  extension  of  the  members  and  consequent  exposure 
of  a  greater  dissipating  surface  hastening  the  effect ;  while  a  contracted 
posture,  with  arms  and  limbs  arranged  close  to  the  trunk,  by  dimin- 
ishing such  area,  retards  to  a  greater  or  less  degree  the  rapidity  of  the 
process  of  fr('(>zing. 

Symptoms. — The  onset  of  symptoms  depends  largely  on  the  par- 
ticular mode  of  exposure.  Thus  the  ordinary  freezing  to  death  \vliich 
occurs  from  prolonged  exposure  to  low  atmospheric  temperature  is 
gradual  in  the  development  of  its  symptom-complex,  while  a  sudden 
immersion  in  cold  water  is  generally  quite  rapid  in  its  effects,  a  few 
minutes'  exposure  often  being  sufficient  to  induce  imconsciousness.  In 
persons  of  vigorous  constitution  the  course  of  symptoms  is  apt  to  be 
more  protracted  than  in  those  weakened  from  various  causes.  In  this 
latter  class  a  rapid,  paroxysm-like  culmination  may  occur  after  but  a 
few  minutes,  reseml)ling  the  so-called  "  congestive  chill."  It  is  to  be 
insisted,  also,  that  death  from  exposure  to  cold  is  not  always  immediate 
in  its  effect,  and  that  the  bodies  of  those  thus  dead  need  not  always  be 
found  in  an  exposed  situation.  A  weakling,  for  example,  may  be  sub- 
jected for  a  time  to  the  influences  of  an  intense  cold,  be  rescued,  and 
develop  the  lethal  symptoms  of  exposure  some  time  after  protection  has 
been  afforded.  An  insane  person  may  l)e  immersed  in  an  icy  bath  for 
its  calmative  effect,  be  removed  and  warmly  covered  to  induce  proper 
reaction.  This  reaction  may  never  come,  although  the  fatal  circulatory 
failure  is  not  distinctlv  recognized  until  hours  after  the  bath. 

In  ordinary  cases  of  expostire  to  cold,  exposure  to  the  cold  atmos- 
phere, for  instance,  the  first  feature  noted  is  the  subjective  sensation  of 
cold,  most  pronounced,  as  a  rule,  in  the  extremities,  lips,  n(^se,  and  ears. 
The  surface  at  first  becomes  pale,  the  skin  contracted  and  harsh,  and 
"  goose-flesh  "  appears  from  the  stimulation  of  the  pilar  muscles.  The 
irregular  stimulation  of  the  superficial  muscles  gives  rise  to  the  well- 
known  creepy  sensations  and  to  shivering.  If  at  this  time  the  surfice 
and  the  deep  temperature  are  taken,  while  the  former  is  found  below 
normal,  the  latter  is  usually  one  or  more  degrees  above  the  normal. 
This  condition  apparently  indicates  an  increased  thermogenesis,  ]irobably 
from  the  active  chemical  changes  induced  within  the  system  mider  the 
influence  of  retained  excretory  materials.  In  this  stage  the  individual 
is  usually  somewhat  exhilarated,  active  in  thought  and  movements,  and 
seeks  to  stimulate  the  circulation  bv  free  motor  exertion,  (irraduallv, 
as  the  exposure  continues,  the  sense  of  chilliness  is  lost,  the  blood 
returns  to  the  skin,  and  the  surface  is  covered  with  a  diffuse  blush  ; 
the  "  goose-flesh  "  disappears,  the  skin  becomes  smooth  and  ap])arcntly 
slightly  swollen,  and  the  tendency  to  shiver  and  the  desire  for  active 
movement  are  gradually  lost.  The  chilly  sensation  is  replaced  by  a 
tingling  or  sense  of  actual  pain.     The  urinary  excretion,  which  during 


168  DEATH    FROM    COLD. 

the  early  stage,  on  account  of  the  heightened  blood  pressure,  Avas 
increased,  is  now  normal  or  perliaps  diminished.  If  the  temperature  is 
again  taken,  the  surface  heat  is  found  to  be  subnormal,  although  to  a 
less  degree  than  in  the  previous  stage,  while  the  internal  temperature 
is  maintained  at  least  slightly  above  normal.  Gradually  the  blush  in 
the  extremities  and  other  distal  parts  of  the  circulation  deepens  to  a 
purplish,  cyanotic  hue  ;  but  after  a  time  the  dilatation  of  the  internal 
vessels  permits  the  blood  to  recede  from  the  general  surface,  leaving  it 
blanched  and  relaxed.  Even  the  surface  of  dependent  parts  may  be  left 
pale  and  bloodless  in  this  terminal  stage,  although  if  the  ouset  of  the 
internal  relaxation  and  circulatory  failure  is  rapid,  such  dependent  sur- 
faces are  generally  left  livid  by  the  retention  of  blood  in  their  structures. 
Various  circumstances  of  protection,  of  local  muscular  contraction,  and 
other  causes  may  likewise  retard  the  recession  of  blood  from  tliis  or 
that  part,  giving  rise  to  livid  blotches  of  irregular  size,  shape,  intensity, 
and  disposition.  Generally  the  hands  and  feet,  nails,  nose,  lips,  and 
ears  remain  blue  and  livid,  and  should  recovery  take  place,  intense 
inflammatory  reaction  may  set  in  or  gangrene  develop  from  the  inten- 
sity of  the  passive  hyperemia.  The  tingling  and  pain  of  the  preceding 
stage  gradually  disappear,  to  be  replaced  by  numbness,  deepening  into 
actual  anesthesia.  During  this  third  stage  the  somatic  temperature, 
both  internal  and  external,  rapidly  falls  to  approximate  that  of  the 
surrounding  medium  after  death.  The  pulse,  which  hitherto  may  have 
shown  no  apprccial)le  change,  is  distinctly  soft  and  weak,  and  may  be 
altered  in  rate  and  rhythm,  indicating  cardiac  labor  and  weakness.  A 
sense  of  oppression  and  fulness  may  be  complained  of  about  the  chest, 
if  the  patient  is  able  to  appreciate  his  sensations,  and  a  slight  irritative 
cough  often  develoi)s  quickly,  witli  a  frothy  and  sometimes  bloody 
expectoration.  The  general  sensibility  of  the  patient  is  progressively 
and  greatly  changed.  A  feeling  of  weakness  and  fatigue  appears,  the 
intellect  becomes  dulled,  there  is  indisposition  to  further  physical  exer- 
tion, and  a  drowsiness  steals  over  the  individual's  senses.  The  feeling 
of  tiredness  becomes  overpowering,  and  although  the  patient  may  appre- 
ciate his  position  and  danger,  utter  carelessness  as  to  the  result  is  mani- 
fested ',  the  somnolence  grows  apace,  and  in  spite  of  every  stimulus  the 
victim  sinks  into  a  sleep  which  soon  deepens  into  coma,  and,  without 
help,  rapidly  passes  into  death.  Sometimes  in  this  unconscious  state, 
or  replacing  it,  epileptiform  or  apoplectiform  convulsions  occur  and 
terminate  the  scene.  Death  usually  occurs  gradually  by  cardiac  failure, 
but  a  syncopal  attack  may  prove  the  terminal  stage ;  and  at  times  the 
respiration  ceases  before  all  signs  of  circulation  have  disappeared. 

Rigor  mortis  appears  at  various  periods  after  death,  largely  depend- 
ing upon  the  physical  exertion  performed  before  death  ;  but,  as  a  rule, 
true  rigor  mortis  appears  slowly.  Rigidity  from  congelation  may 
mask  that  i^rodaced  by  the  usual  coagulation  of  the  muscular  substance. 

The  time  occupied  in  the  process  of  freezing  to  death,  as  already 
stated,  varies  considerably,  but  usually  several  hours  are  consumed 
before  the  termination  is  reached ;  and  in  vigorous  subjects  the  different 


POSTMORTEM    APPEARANCES.  169 

stages  will  require  an  exposure  of  a  number  of  hours,  if  a  fair  protec- 
tion has  been  possessed  by  the  individual,  before  death  takes  place. 
Immersion  in  cold  water,  exposure  to  cold  air  and  dampness  combined, 
as  in  wet  clothes  on  a  cold  day,  other  things  being  equal,  produce  more 
rapid  and  serious  effects  than  exposure  to  a  cold  but  dry  atmosphere 
alone.  The  personal  resistive  power  is  also  of  mucii  importance ; 
weaklings  from  any  cause  succumbing  with  much  greater  rapidity  than 
persons  possessing  an  ordinarily  strong  constitution.  riius  it  is  not 
imjH-obable  that  quite  a  decided  proportion  of  the  deaths  which  occur 
ra[)idly  some  hours  after  a  severe  oj)eration,  without  ai)i)urent  cause,  are 
in  reality  due  to  the  influences  of  a  temperature  perhaps  but  little 
below  that  customarily  endured  ;  and  in  localities  subject  to  sudden  and 
decided  changes  of  temperature,  as  in  our  Gulf  States  in  ^vinter,  hos- 
pital officials  fear  greatly  the  sudden  oncome  of  a  "norther"  lest 
their  weaker  patients  may  succumb  from  the  change  of  temperature 
occurring  even   in  a   protected   ward. 

Postmortem  Appearances. — The  appearances  met  in  the  body 
after  death  from  cold  are  few,  but  are  fairly  distinctive  where  the 
exposure  has  been  to  actual  freezing  temperature,  and  may  serve  to 
determine  W' ith  some  accuracy  that  death  has  occurred  by  reason  of  such 
exposure.  In  such  cases  the  surface  of  the  body  is  extremely  pale ; 
but  here  and  there,  not  merely  in  dependent  parts,  livid  blotches,  such 
as  are  usually  seen  in  ordinary  death  in  the  dependent  parts  of  the 
surface,  may  be  found.  These  patches  of  lividity  have  no  regular 
position,  shape,  size,  or  depth  of  hue  ;  and  may  be  entirely  absent. 
The  lips,  ears,  and  terminal  phalanges  are  usually  blue.  The  skin, 
especially  about  the  thicker  parts,  as  the  ])alms  and  soles,  is  apt  to  be 
wrinkled.  There  is  nothing  chai'acteristic  about  the  postiu-e  of  the 
body,  unless  it  is  found  in  a  curled-up  position  indicating  some  effort  on 
the  part  of  the  victim  to  preserve  his  warmth  before  becoming  uncon- 
scious. The  pupils  are  dilated.  There  may  be  a  little  bloody  and 
frothy  mucus  in  the  mouth  and  throat. 

On  opening  the  body,  the  interior  vessels  are  found  full  of  blood, 
and  the  larger  viscera,  including  the  brain,  but  sometimes  excluding 
the  lungs,  are  found  deeply  congested.  Patches  of  hemorrhage,  from 
extreme  engorgement  probably,  have  been  noted  by  some  observers  in 
the  gastric  and  intestinal  mucous  membrane.  When  the  lungs  are 
engorged,  it  is  not  unusual  to  find  small  liemorrhages  and  submucous 
effusions  in  the  bronchial  tubes.  Occasionally,  also,  small  hemorrhages 
into  the  uriniferous  tubules  of  the  kidneys  are  to  l)e  found.  The  brain 
is  occasionally  also  the  seat  of  small  hemorrhagic  patches,  thus  account- 
ing for  the  a])oplectiform  seizures  sometimes  met  with  in  the  terminal 
stages.  The  heart  is  distended  in  all  its  cavities.  The  a|)pearauce  of 
the  blood  is  peculiar,  being  of  a  light  arterial  hue  and  nnich  more  fluid 
than  ordinarily  is  the  case  after  death.  Small  clots  are  often  found  in 
the  heart  cavities  and  larger  vessels,  but  the  fluidity  of  the  blood  is  a 
uniform  characteristic. 

These  changes  are  met  with   unifbnnly  oidy  in  those  who  actually 


170  DEATH    FROM    COLD. 

"  freeze  to  death,"  and  are  not  so  generally  met  with  in  those  whose 
death  has  occurred  without  such  prolonged  exposure  to  an  intense  cold, 
as  is  presupposed  in  these  cases.  Thus  infants,  who  succumb  earlier 
and  from  less  intense  cold  than  ordinary  adults,  are  very  apt  to  haye 
more  wide-spread  liyiditj  of  the  surface  of  the  body,  death  haying 
taken  place  from  circulatory  failure  before  the  usual  determination  of 
the  surface  blood  to  the  interior  had  been  completed.  So,  also,  in 
persons  whose  condition  of  yasotaxis  Avas  poor  even  before  exposure, 
and  who,  in  consequence,  probably  died  in  syncope  after  brief  exposure, 
the  surface  appearance  is  that  usually  met  in  ordinary  deaths — moderate 
degree  of  pallor  if  superior  areas  and  liyidity  of  dependent  ones.  In 
these  latter,  also,  the  arterial  hue  of  the  blood  and  failure  to  coagulate 
is  not  noted  with  any  certainty. 

Of  the  appearances  given,  while  as  a  group,  taken  into  consideration 
Avith  the  surroundings  of  the  case,  they  constitute  a  fairly  certain  evi- 
dence of  the  mode  of  death,  none  is  absolutely  sure.  A  number  of 
poisons,  for  example,  among  them  prominently  the  cyanids,  are 
cajxible  of  producing  the  fluid  consistency  and  arterial  hue  of  the 
blood ;  while  a  large  number  of  toxic  agents  and  disease  conditions 
might  duplicate  the  internal  congestions  noted.  The  irregular  livid 
patches  ujion  the  pallid  surface  are  probably  most  nearly  certain  evi- 
dence of  the  influence  of  cold,  and  yet  these  are  not  by  any  means  con- 
stant and  may  be  closely  simulated  in  various  states  of  poisoning  and 
disease.  They  are  probably  most  often  caused  by  some  interference  to 
the  determination  of  the  blood  from  the  surface  to  the  interior  in  the 
onset  of  the  third  stage  of  the  process.  Thus  the  compression  of  an 
eflferent  vein  by  some  external  pressure,  by  some  pi'essure  from  ])osture, 
or  by  some  irregular  constriction  of  a  neighboring  muscle  could  \^•ell 
account  for  the  phenomenon. 

In  the  examination  of  bodies  of  those  supposed  to  have  died  from 
the  effects  of  exposure  to  cold  it  must  not  be  lost  sight  of  that  death 
may  have  occurred  from  very  diflerent  causes,  and  even  in  the  existence 
of  the  foregoing  signs  careful  examination  of  the  body  for  signs  of 
other  disease  and  of  violence  must  be  made.  Persons  freezing  to  death 
seek  naturally,  as  a  rule,  a  sitting  or  recumbent  posture  as  a  relief 
from  fatigue,  and  marks  of  violence  are  therefore  always  to  be  regarded 
with  much  suspicion  when  found  in  such  cases.  The  marks  of  violence 
need  not  be  of  such  a  character  as  to  indicate  a  necessarily  fatal  violence 
in  order  to  implicate  another,  since  it  is  well  known  that  in  the  wounded 
refrigeration  is  more  uniformly  and  seriously  effective  than  in  the  nor- 
mal. Nor  is  it  to  be  lost  sight  of  that  mere  frozen  rigidity  is  not  in 
itself  an  indication  that  death  occurred  from  cold,  since,  of  course,  solidi- 
fication from  freezing  cannot,  in  the  nature  of  things,  occur  generally 
throughout  the  body  until  after  actual  death — and  this  in  spite  of  the 
fact  that  cold-blooded  animals,  as  fish,  may  sometimes  be  resuscitated 
after  having  been  frozen  stifl",  and  that  small  portions  of  warm-blooded 
animals,  cock's-combs,  for  example,  may  become  brittle  from  cold,  while 
the  animal  retains  its  vitality.     A  matter  of  some  importance,  indicated 


LEGAL   CONSIDERATIONS.  171 

in  the  writings  of  various  legal  [)hysicians,  is  the  absence  of  all  signs 
of  putrefaction,  and  from  this  the  inference  arises  that  if  congelation 
has  been  continuous,  any  such  signs  must  uulicate  the  death  of  the 
individual  ])rior  to  the  freezing  of  the  body.  Yet  it  is  to  be  recalled 
that  an  actually  freezing  tem{)erature  is  not  always  necessary  to  produce 
death  from  cold,  and  that  slight  })utrefaction  may  occur  in  temperatures 
sutHcient  to  produce  death  in  the  weak.  Moreover,  the  occurrence  of 
weather  permitting  decomposition  in  the  interval  between  death  and  the 
discovery  of  the  body  must  be  kept  in  mind. 

Treatment  of  Those  Dying  from  Exposure  to  Cold. — 
The  indications  lor  the  care  of  persons  in  whom  death  from  cold  is 
imminent  include  the  preservation  of  the  remaining  l)ody  warmth,  the 
provision,  in  every  way  possible,  of  warmth  to  make  good  the  loss 
which  has  occurred,  and  the  maintenance  and  stimulation  of  the  flag- 
ging circulation.  After  immediate  reaction  has  been  obtained,  the  sub- 
sequent measures  should  be  directed  to  overcome  the  more  or  less  per- 
sisting etfects  of  the  wide-spread  internal  congestion,  especially  of  the 
kidneys,  alimentary  tract,  lungs,  and  brain,  and  the  establishment  of  full 
excretion  and  of  nutrition.  The  first  of  these  indications  demands  the 
immediate  application  of  a  large  amount  of  light,  non-conducting  cloth- 
ing.' The  patient  should  immediately,  or  as  quickly  as  possible,  be 
placed  in  a  warm  bed.  Hot  diffusible  stimulants  should  be  admin- 
istered, and  hot  bottles  and  other  external  heat  applied  to  the  surface. 
The  skin  should  be  thoroughly  rul)bed  with  hot  towels.  Among  the 
stimulants  indicated,  whisky,  strychnin,  and  digitalis  are  prol)ably  the 
best.  Hot  saline  enemata  may  l)e  administered  with  benefit.  The 
body  should  be  placed  in  such  position  that  determination  of  the  blood 
from  the  brain  will  naturally  occur ;  but  with  any  sign  of  syncope  the 
head  should  be  lowered  at  once.  After  the  reaction  has  been  estab- 
lished, the  further  treatment  of  the  case  resolves  itself  into  that  of  the 
nephritis  and  other  inflammations  which  may  arise,  and  must  necessarily 
vary  greatly  with  the  intensity  and  special  prominence  of  the  involve- 
ment of  this  or  that  organ.  In  every  case,  however,  the  necessity  for 
the  care  of  the  nutrition  and  the  establishment  of  free  renal  and  dermal 
excretion  must  enter  largely  into  the  special  treatment,  in  order  to 
afford  the  means  of  maintaining  the  chemical  activities  upon  which 
thermogenesis  depends  and  in  order  to  free  the  system  of  the  deleterious 
products  which  have  formed  or  accumulated  during  the  period  of 
refrigeration. 

I/egal  Considerations. — Death  from  exposure  to  cold  is  usually 
accidental,  but  questions  of  responsibility  may  arise  as  to  homicide  in 
exposure  of  babes,  children,  the  insane,  or  the  aged,  and  of  contribu- 
tory negligence  in  the  case  of  weaklings  and  sick  and  wounded  persons. 
Intentional  exposure  or  criminal  negligence  can  naturally  rarely  be 
charged  in  connection  with  healthy  and  developed  individuals,  nor  is 
the  possibility  of  suicide  by  the  means  in  question  of  sufficient  impor- 
tance to  demand  attention.  Instances  of  intentional  destruction  are 
not  infrequent,  however,  especially  in  the  newly  born,  particularly  when 


172  DEATH    FROM    COLD. 

the  child  was  illegitimate.  In  such  suspected  instances  it  is  to  be  kept 
clearly  in  mind  that  babes,  and  especially  those  prematurely  or  poorly 
developed,  may  perish  from  comparatively  slight  refrigeration,  and  that 
it  is  not  necessary  to  establish  the  prevalence  of  actually  freezing 
weather  during  the  exposure.  The  environments  of  the  mother  at  the 
time  of  parturition  are,  however,  to  be  considered,  inasmuch  as  she  may 
have  been  at  the  time  physically  unable  to  render  the  necessary  attention 
to  her  offspring ;  yet  in  such  event  she  may  be  held  liable  to  the  charge 
of  contributory  negligence  for  failing  to  provide  the  assistance  usual  to 
childbed  in  civilized  communities.  In  infanticide  by  exposure,  further, 
a  systematic  incompleteness  of  protection  from  cold  may  procure  the 
desired  death  of  the  babe,  and  yet  at  the  time  of  actual  death  the  sur- 
roundings be  free  from  objection,  death  occurring  from  failiu'e  to  react 
from  the  effects  of  previous  partial  or  complete  exposure.  Death  from 
intentional  or  ignorant  exposure  by  immersion  in  cold  water  has  been 
known  in  case  of  such  infants  and  children. 

Among  the  insane,  incarceration  in  cold  rooms  or  other  insufficiently 
protected  places,  and  the  enforced  use  of  cold  baths  have  occasionally 
resulted  in  the  death  of  the  patient.  The  actual  motive  of  murder  is 
usually  absent  here,  the  exposure  resulting  from  carelessness  or  ignor- 
ance. Sometimes,  in  asylums  and  elsewhere,  the  cold  bath  is  used  by 
unthinking  or  unscrupulous  attendants  for  purposes  of  punishment 
of  some  refractory  inmate  or  for  its  calmative  after-effect,  and  death 
has  been  known  to  occur  in  consequence.  As  a  rule,  however,  in  well- 
regulated  institutions  for  the  insane  such  an  act  is  beyond  the  right 
of  the  nurses  ;  and  where  the  power  is  usurped  without  the  authority  of 
the  physician  in  charge,  the  attendant  should  be  held  legally  and  fully 
responsible.  So,  also,  for  the  aged,  the  sick,  or  the  wounded,  criminal 
or  ignorant  failure  to  protect  against  cold  may  directly,  or  by  causing 
serious  complications,  lead  to  deaths  and  give  origin  to  legal  inquiry. 
In  all  these  cases,  especially  when  the  intentional  exposure  or  the 
is^norant  neo-lect  is  sousrht  to  be  concealed,  the  caution  alreadv  men- 
tioned  must  he  emphasized,  that  the  full  category  of  postmortem  signs 
already  mentioned  is  likely  to  be  absent ;  and  the  interests  of  right 
demand  that  such  failure  to  establish  fully  the  evidence  of  complete 
congelation  shall  not  be  held  to  invalidate  the  charge  if  sustained  by 
other  evidence.  The  postmortem  evidences  enumerated  more  fre- 
quently are  discovered  in  their  full  complex  among  those  accidentally 
frozen  than  among  those  dead  from  intentional  or  careless  exposure  to 
cold. 

Finally,  the  question  of  contributory  negligence  may  be  held  against 
physicians  and  others  responsibly  in  attendance,  from  failure  reasonably 
to  j^ractise  the  measures  indicated  for  the  relief  of  those  threatened  by 
death  from  exposure  to  cold,  without  justification  of  special  circum- 
stances. 


DEATH  FROM  HEAT.  173 


DEATH  FROM  HEAT. 


Exclusive  of  the  effects  of  bums  and  scalds,  heat  luav  produce  lethal 
effects  by  wliat  is  commonly  known  as  sunstroke,  heat-stroke,  or 
thermic  fever.  This  condition,  ])resentin«,^  several  ditfcrent  phases, 
usually  occiu's  from  exposure  to  the  direct  rays  of  the  sun,  but  may  be 
imluced  by  exposiu-e  to  any  excessive  external  heat  if  of  sufficiently 
long  duration.  Cases  of  fatal  heat-stroke  most  frequently  occur  where, 
in  connection  with  the  direct  influence  of  the  heat-rays,  an  insufficient 
amount  of  atmospheric  circulation  prevails,  especially  if  the  air  is 
humid  enough  to  retard  the  evaporation  of  perspiration  to  an  appre- 
ciable degree. 

In  the  action  of  heat,  as  in  that  of  cold,  several  stages  of  severity 
may  be  distinguished,  and  there  are  at  least  two  modes  of  manifesta- 
tion of  the  fatal  stage.  As  in  case  of  cold,  the  very  young  and  the 
very  old,  the  sick,  the  weak,  and  the  wounded  first  feel  the  effects  of 
exposure  of  the  general  system  to  excessive  degrees  of  temperature,  and 
it  is,  therefore,  among  these  classes  that,  as  a  rule,  the  milder  stages  of 
thermic  fever  are  brought  to  notice  ;  while  in  the  strong,  these  early 
signs  unnoted,  the  process  is  permitted  to  proceed  to  the  fullest  mani- 
festation of  heat  collapse  or  of  the  feljrile  form  of  coup  de  soleil. 

The  effects  of  heat  in  milder  degree  are  held  by  many  to  be  the 
cause  of  at  least  a  large  proportion  of  the  deaths  from  cholera  infontum 
among  the  inflints  of  large  and  hot  cities  during  the  prevalence  of  the 
heated  term.  The  male  sex  among  adults  is  more  frequently  affected  than 
the  female,  mainly  because  the  latter  sex  is  less  liable  to  prolonged  exjio- 
sure  to  excessive  temperatures  and  bodily  fatigue.  As  a  rule,  the  inhabi- 
tants of  cooler  climates,  upon  immigration  to  a  warmer  zone,  are  more  sub- 
ject to  the  evil  effects  of  heat  than  the  natives  ;  and  thus  it  arises  that  gen- 
erally the  dark-skinned  races  are  comparatively  exempt  from  the  severe 
results  of  such  exposure.  Fatigue,  both  muscular  and  mental,  but 
especially  the  former,  seem  to  increase  materially  the  liability  to  the 
untoward  effects  of  exposure  to  high  temperatures.  The  high  rate  of 
occurrence  and  fatality  of  heat-stroke  among  armies  on  the  march  or  in 
battle  is  probably  largely  dependent  on  this  factor.  Heavy  and  warm 
clothing,  as  the  uniforms  of  soldiers,  may  be  an  important  element. 
Intemperance  is  generally  placed  auKjng  the  first  of  the  etiologic  in- 
fluences, and  clinically  this  claim  seems  well  sustained  ;  but  there  are 
those  who  regard  it  as  but  a  minor  agent.  It  is  held  l>y  these  latter 
that  the  habit  of  intemperance  and  physical  exertion  leading  to  fatigue 
are  coincident  in  the  laboring-classes,  among  whom  heat-stroke  is  most 
commonly  encountered,  and  if  the  intemperate  of  the  richer  classes  were 
also  subject  to  great  bodily  fatigue  during  exjiosure  to  heat,  the  results 
would  be  proportionate  in  the  two  groups.  There  is,  doubtless,  some 
truth  in  this  contention,  but  theoretically  one  would  expect  that  the 
vascular  alterations  consequent  u]ion  prolonged  habits  of  intemperance 
would  decidedly  favor  the  circulatory  failure  in  insolation. 

The  severe  manifestations  of  heat-exposure  usually  occur  durmg 


174  DEATH    FROM    HEAT. 

the  periods  of  greatest  physical  exertion  in  the  hot  hours  of  summer 
days ;  but  when  the  nights  are  also  hot,  the  phenomena  of  the  con- 
dition induced  may  present  themselves  during  the  hours  of  rest. 
Exposure  to  the  direct  rays  of  the  sun  is  most  frequently  productive 
of  the  untoward  effects,  and  by  far  the  greatest  nvimber  of  cases  occur 
in  those  working  in  the  heat  of  closely  built  cities  of  the  coast  without 
the  favoring  influence  of  free  breezes.  Yet  protection  from  the  sun's 
rays  by  no  means  grants  immunity,  for  a  large  proportion  of  the  severe 
cases  takes  place  in  hot,  close  manufactories,  furnace-rooms,  and  similar 
buildings.  The  degree  of  heat  requisite  to  cause  pathologic  effects 
must  of  necessity  vary  much  with  the  thermotaxic  power  of  the  indi- 
vidual and  with  the  relative  humidity  and  movement  of  the  surrounding 
atmosphere.  In  closely  built  cities,  in  moist  climates,  heat-strokes  are 
apt  to  appear  when  the  thermometer  registers  from  80"^  to  85°  F.  and 
upward  ;  on  dry  western  plains,  where  the  atmospheric  movement  is 
free,  sunstrokes  are  not  common  even  when  the  heat  of  the  sun  registers 
as  high  as  115°  or  120°  F.  Brief  exposure  to  much  higher  tempera- 
tures, as  in  fire-rooms  of  great  ocean  steamers,  where  the  thermometer 
is  known  sometimes  to  register  as  much  as  160°  F.,  is  possible  without 
material  injury  if  free  circulation  of  air  is  provided. 

The  injudicious  use  of  water  by  those  exposed  to  excessive  warmth 
may  prove  dangerous.  As  a  rule,  M'liere  no  physical  exertions  have 
been  coexistent  with  the  heat-exposure,  the  drinking  of  cold  water  is  not 
injurious,  but  aids  in  lowering  the  body-heat ;  but  carelessness  in 
drinking  large  amounts  of  iced  liquid  by  those  who  are  overheated  and 
fatigued  has  been  known  to  produce  sudden  death.  It  is,  however, 
advisable  that  small  amounts  of  cool  liquids  be  drunk  from  time  to 
time,  both  for  the  immediate  effect  of  cooling  the  parts  with  which  it 
comes  in  contact  and  in  order  to  promote  free  perspiration.  Sudden 
immersion  of  the  heated  body,  as  in  the  cold  plunge  of  a  Turkish  bath, 
when  there  is  no  element  of  fatigue  attending,  is,  as  a  rule,  refreshing 
and  invigorating  in  health  ;  but  the  same  practice  after  overheating  by 
severe  labor  in  a  heated  atmosphere  has  frequently  produced  fatal  con- 
sequences. 

Symptoms. — Aside  from  such  poorly  understood  influences  of 
excessive  heat-exposure  as  are  believed  by  many  to  underly  at  least  a 
number  of  cases  of  cholera  infantum  or  summer  sickness  of  children, 
there  are  three  fairly  distinct  trains  of  symptoms  arising  from  such 
exposure.  The  first  of  these  is  to  be  regarded  as  a  mild  form  of  ordi- 
nary thermic  attack,  and  has  been  described  under  various  names,  as 
simple  continued  fever,  ardent  continued  fever,  and  has  been  con- 
founded with  various  acute  febrile  afl'ections — as,  for  example,  typhoid 
fever.  This  phase  of  thermic  fever  may  run  a  varied  course — from 
several  days  to  a  week  or  more.  The  attack  usually  comes  on  rapidly, 
sometimes  with  a  chill  and  transient  pallor  of  the  surface  ;  the  fever 
quickly  rises  to  103°  or  105°  F.,  and  in  severe  cases  may  be  more 
intense.  The  face,  and  often  the  body,  is  generally  covered  with  a 
diffuse  blush.     Headache  of  more  or  less  intensity  is  complained  of; 


SYMPTOMS.  175 

there  may  be  intolerance  of  Ht>:lit  and  sound,  and,  in  tlie  severe  forms, 
delirium.  There  are  anorexia,  nausea,  and  voniitinj; ;  either  diar- 
rhea or  constipation  may  1)0  ]iresent.  Tiie  patient  voids  hut  a  small 
amount  of  highly  colored  urine.  The  pulse  is  generally  full  and 
hard  ;  resj)irations  are  ra[>itl  and  rather  shallow.  There  is  considerable 
prostration,  malaise,  and  usually  more  or  less  muscular  pain.  In  the 
United  States  the  condition  is  apt  to  be  of  short  duration,  and  grad- 
ually subsides  in  a  few  days.  In  the  severer  forms,  such  as  are  met 
with  in  India,  the  attack  is  often  ftital,  passing  into  coma  and  death 
in  three  or  four  days,  and  sometimes  terminating  in  apoplectiform  con- 
vulsions. 

The  second  form  is  that  known  as  heat  collapse.  It  is  not  often 
seen  in  this  country  in  its  most  typical  development,  but  is  represented 
by  the  common  heat=exhaustion  occurring  among  laborers  in  the 
height  of  the  heated  term,  and  is  especially  likely  to  occur  in  persons 
unaccustomed  to  heavy  work  who  endeavor  to  perform  an  arduous 
physical  task  under  such  circumstances.  This  milder  form  of  heat- 
exhaustion  comes  on  gradually  at  first.  The  subjective  sensation  of 
heat  becomes  intense,  the  perspiration  scanty,  the  countenance  flushed ; 
there  is  throbbing  pain  in  the  temples  and  the  mouth  is  dry.  After 
perhaps  half  an  hour  of  such  experience  there  is  felt  an  uncertain 
weakness  about  the  epigastrium,  cardiac  palpitation  may  be  noted,  the 
surface  becomes  pale  and  is  bathed  in  perspiration,  and  chilliness  and 
great  muscular  weakness  cause  discomfort.  The  headache  rapidly 
diminishes,  nausea  and  vomiting  may  come  on  quickly,  and  the  patient 
may  have  intense  griping  and  urgent  and  repeated  desire  to  defecate, 
with  the  evacuation  of  profuse  watery,  sometimes  bloody,  passages. 
Rest  in  the  recumbent  posture,  quiet,  some  simple  cardiac  stimulant, 
and  a  mild  astringent  will,  as  a  rule,  in  the  course  of  a  few  hours,  or  a 
day  or  more  at  most,  accomplish  the  desired  cure.  The  grave  form  of 
heat  collapse  is  far  less  frequent,  but  is  by  no  means  unknown  in  this 
country.  It  may  develop  from  the  milder  form  just  described,  or  may 
occur  without  appreciable  warning.  Tlie  patient  may,  in  the  midst  of 
his  work,  be  suddenly  seized  and  fall  unconscious.  The  surface  is  pale, 
is  bathed  with  profuse  perspiration,  and  feels  cold  to  the  touch.  The 
pulse  is  rapid,  feeble,  and  irregular ;  the  temperature,  taken  in  the 
mouth  or  rectum,  is  subnormal.  Unconsciousness  is  often  incomplete, 
and  may  be  accompanied  by  a  low  muttering  delirium.  Such  a  case, 
if  left  to  itself  or  if  remedial  measures  fail,  will  die  from  cardiac  failure 
or  occasionally  from  respiratory  failure. 

The  third  and  claa'^ic  form  of  heat-stroke  is  the  well-known  sun= 
stroke,  coup  de  soleil,  heat  apoplexy,  insolation,  or  thermic  fever. 
The  conditions  of  its  development  are  the  same  as  of  the  other  forms. 
Unknown  personal  factors  determine  the  jiresentation  of  this  rather  than 
of  the  other  varieties.  Usually  it  is  preceded  by  recognizal)le  synqitoms 
for  perhaps  half  an  hour  or  more  before  the  actual  explosion  ;  but  it  may 
occur,  like  the  grave  form  of  heat-exhaustion,  with  great  suddenness 
and  no  appreciable  warning.       In  ordinary  cases,  after  prolonged  ex- 


176  DEATH    FROM   HEAT. 

posure  the  patient  complains  of  headache  and  an  uncomfortable  sub- 
jective sensation  of  heat.  As  the  external  heat  is  maintained  and  the 
individual  persists  in  physical  exertion,  perspiration  becomes  less  and 
less  marked  and  after  a  time  disappears.  Dizziness  is  felt,  and  the 
feeling:  of  heat  becomes  excessive.  The  face  and  more  or  less  of  the 
general  surface  become  congested  ;  and  suddenly,  generally,  as  if  shot, 
the  patient  becomes  im conscious  and,  if  in  the  erect  position,  falls. 
The  physician  rarely  sees  the  patient  before  this  stage  of  the  illness, 
and  is  frequently  unable  to  obtain  any  history  of  the  premonitory 
symptoms  described.  The  surface  is  almost  invarial)ly  red  and 
extremely  hot  to  the  touch  ;  the  pulse  is  full  and  bounding,  usually 
rapid,  but  without  tension  ;  the  respirations  are  unaltered  or  stertorous  ; 
coma  is  usually  complete  or  attended  with  delirium ;  and  temperature 
is  much  elevated,  sometimes  reaching  112°  or  115°  F.  A  peculiar 
pungent  odor  is  nearly  always  appreciable  ;  involuntary  dejections  hav- 
ing this  same  odor  are  frequent.  The  pupils  are  usually  contracted. 
The  patient  may  lie  perfectly  motionless  as  if  paralyzed,  or  there  may 
be  marked  restlessness,  subsuUus  tmdinum,  or  even  convulsions. 
Fatal  cases  are  generally  terminated  in  the  course  of  half  an  hour  or 
an  hour.  Occasionally  the  attack  and  its  fatal  outcome  are  truly 
fuJcjurantc,  death  taking  place  from  syncope  at  once.  Commonly  the 
temperature  in  these  fatal  cases  mounts  from  the  initial  moderate  hyper- 
pyrexia to  the  maximum,  which  is,  on  an  average,  108°  or  109°  F., 
exceptionally  five  or  six  degrees  higher,  as  already  indicated.  Tlie 
pidse  becomes  more  and  more  rapid,  losing  in  its  strength  and  fulness  ; 
the  respirations  become  more  and  more  impeded  ;  nuicous  rales  appear 
in  the  bronchi  and  trachea  ;  the  surface  of  the  body,  by  reason  of 
cardiac  failure  and  internal  vascular  dilatation,  becomes  pale,  and  death 
occurs  either  from  asphyxia  of  central  origin  or  by  rapid  or  slow  circu- 
latory failure.     The  case  may  be  terminated  by  apoplectiform  seizures. 

In  addition  to  such  cases  it  should  be  remembered  that  milder  forms 
may  be  encountered,  in  which  complete  or  partial  consciousness  may  be 
preserved,  but  where  the  sudden  onset  and  the  prevalence  of  the  height- 
ened temperature  and  of  the  other  symptoms  justify  a  classification 
among  the  true  sunstrokes. 

The  differences  between  these  two  forms  of  grave  heat  injury,  while 
clinically  very  striking,  fundamentally  are  probably  merely  those 
dependent  on  the  point  of  application  of  the  influences.  The  typical 
heat-exhaustion  manifests  a  vascular  dilatation  and  relaxation  as  the 
main  stage  of  its  course,  which  in  the  true  sunstroke  is  represented  but 
briefly  in  the  terminal  collapse  or  synco]>e  ;  wliile  the  important  period 
of  circulatory  stimulation  and  peripheral  hyperemia  of  sunstroke  in  heat 
collapse  is  of  but  brief  duration  or  perhaps  entirely  absent.  Heat 
collapse,  then,  from  a  pathologic  point  of  view  is  really  a  protracted 
form  of  the  terminal  period  of  coup  de  soleil,  and  as  such  is  a  more 
advanced  and  serious  state  than  the  latter.  The  })allor,  tlie  tremendous 
heat  dissipation,  leading  to  a  subnormal  temperature,  the  clammy,  pro- 
fuse perspiration  are  all  significant  of  such  an  mterpretation.     Why 


POSTMORTEM    API'EARANCES.  177 

such  (lift'erence  of  result  shoultl  occur  is  not  uiulcrstood,  hut  it  is 
nrohahlc  that  any  preexisting  cause  accountinij;  for  lack  of  vascular 
tone,  absohite  or  relative,  must  have  some  influence  in  hastening  the 
oncome  of  the  stage  of  circulatory  paresis.  DiiTcrences  in  the  degree 
of  heat-exposure  and  accumulation  of  body-heat  explain  the  possi- 
bility of  persistence  of  such  paresis  in  heat  collapse  for  a  longer  time 
than  in  true  sunstroke  before  fatal  termination.  On  the  other  hand, 
the  accunuilation  of  body-heat  from  external  sources,  from  increased 
chemical  changes  withiu,  from  liiilure  of  thermo-inhibitory  centers,  and 
from  failure  of  the  dissipating  influence  of  the  overworked  sweat-glands 
should,  in  the  nature  of  things,  precipitate  a  more  serious  and  therefore 
more  brief  period  of  vascular  and  cardiac  failure,  and  should  terminate 
life  more  quickly  when  once  this  stage  of  collapse  or  syncope  is  reached. 

When  in  either  form  a  flivorable  termination  takes  place,  recovery  is 
apt  to  be  slow  and  attended  by  periods  of  relapse ;  and,  as  is  to  be 
expected  from  the  greater  disturbance  of  thermotaxis  in  sunstroke,  more 
protracted  and  uncertain  in  the  latter  form.  Persons  who  recover  usu- 
allv  retain  functional  or  structural  sequels,  of  which  the  most  charac- 
teristic is  a  srreat  idiosvncrasv  to  the  effects  of  anv  form  of  heat. 
Such  persons  are  often  most  uncomfortable  in  temperatures  previously 
pleasurable  to  them,  are  unable  to  sustain  the  heat  of  a  stove  in  winter 
in  the  same  room  with  them,  and  suffer  intensely  from  the  heat  of 
summer.  They  may  manifest  very  protean  nervous  and  vasomotor 
svmptoms,  but  most  frequently  complain  of  headache  and  vertigo  when 
influenced  by  heat.  Epilepsy  and  insanity  may  follow  insolation  and 
persist  throughout  the  life  of  the  patient.  jVIeningeal  thickenings  and 
adhesions  are  frequently  found  as  a  structural  basis  in  such  cases, 
indicating  that  meningitis  had  developed  at  the  time  of  the  original 
attack. 

Postmortem  Appearances. — As  a  rule,  the  surface  is  pale,  with 
the  usual  patclies  of  lividity  in  dependent  parts  ;  and  as  in  death  from 
freezing,  but  not  so  frequently,  there  may  be  areas  of  lividity  even  on 
the  superior  surfaces.  Petechiae  may  also  be  noted,  probal)ly  as  the 
result  of  su]ierficial  hyperemia  and  the  altered  blood  crasis.  Post- 
mortem rigidity  usually  occurs  quickly  and  is  of  brief  duration.  On 
opening  the  Ijody  the  interior  vessels,  as  a  rule,  are  found  very  full, 
especially  the  veins ;  and  the  right  heart  is  generally  distended.  The 
heart,  if  the  autopsy  is  held  early,  is  found  contracted  on  the  left  side, 
probably  as  the  result  of  marked  and  early  contraction  from  coagulation 
of  the  muscle  ]>rotoplasm  ;  but  if  the  autopsy  is  postponed  for  much 
over  an  hour  after  death,  this  contraction  is  not  to  be  noted,  and  the 
heart  is  flabby  and  relaxed  throughout.  The  endocardium  and  intima 
of  the  vessels  often  show  areas  of  reddish  discoloration  from  stain- 
ing with  diffused  blood-pigment.  The  blood  shows  little  tendency 
to  clot,  and  is  dark  and  fluid,  sometimes  almost  gummous.  The  most 
notable  alteration  is  in  the  ])lasma  elements,  the  fluid  being  frequently 
stained,  its  fibrin-forming  element  altered,  and  the  normal  alkalinity 
markedly  diminished.     The  corpuscles  show  little  change  in  number  or 

Vol.  I.— 12 


178  DEATH    FROM    HEAT. 

structure,  but  many  are  paler  than  normal.  There  is  marked  tendency 
to  assume  a  crenated  form,  and  there  are  numerous  blood  plaques.  The 
white  corpuscles  are  usually  slightly  increased.  The  lungs  are  generally 
somewhat  congested  ;  the  meningeal  vessels  are  full,  and  occasionally 
small  petechial  patches  are  found  in  the  brain  substance.  Very  rarely 
a  slight  inflammatory  exudate  may  be  found  in  the  pia  mater,  especially 
upon  the  convexity  of  the  brain.  The  liver,  spleen,  and  alimentary 
mucous  membranes  are  congested  and  soft.  The  kidneys,  as  a  rule, 
show  little  alteration,  although  occasionally  there  is  slight  congestion. 

Putrefaction  appears  very  early  in  these  cases,  and  it  is  held  by 
many  that  the  relaxed  state  of  the  heart,  invariably  met  in  bodies 
brought  to  section  some  hours  after  death,  should  be  regarded  as  a 
result  of  such  alteration.  The  writer  is  not  disposed,  however,  to 
accept  the  contracted  appearance  met  in  most  instances  when  section 
is  made  at  once  after  death  as  a  necessary  indication  that  death  must 
have  occurred  from  other  direct  cause  than  heart  failure,  but  would 
seek  to  explain  it  upon  the  same  ground  as  the  contraction  of  any  other 
unopposed  muscle  in  rigor  mortis,  the  circulatory  effort  being  mainly 
centered  in  these  cases  in  the  veins  and  venous  side  of  the  heart,  wliich 
is  prevented  from  assuming  the  same  contracted  appearance  by  the 
opposition  of  the  large  mass  of  inclosed  blood. 

Treatment. — The  treatment  of  ordinary  thermic  fever  can  only  in 
a  general  sense  be  of  legal  interest,  and  may  therefore  be  dismissed 
without  further  consideration.  The  treatment  of  the  two  grave  forms 
of  the  effects  of  heat-exposure  is  necessarily  as  opposite  as  are  the 
clinical  conditions  themselves.  In  heat  collapse  the  great  circulatory 
depression  and  overdissipation  of  heat  are  to  be  counteracted.  For  the 
latter  purpose  the  hot  bath,  followed  by  the  application  of  dry  heat  to 
the  surface,  and  friction  of  the  surface  with  hot  towels  or  with  some 
stimulant  lotion,  as  tincture  of  capsicum,  may  be  employed.  Hot 
enemata  of  salines,  with  alcohol  or  other  stinndant,  should  also  be 
administered.  Hypodermic  administration,  in  order  not  to  disturb  the 
stomach,  of  digitalis,  strychnin,  alcohol,  ammonia,  ether,  or  other  cir- 
culatory stimulants  should  be  given  without  delay.  When  convulsions 
seem  imminent,  small  doses  of  morphin  hypodermically  administered 
are  sometimes  beneficial. 

In  the  febrile  form,  or  true  sunstroke,  the  relief  of  the  hyperpyrexia  is 
the  main  indication.  As  soon  as  possible  the  patient  should  be  removed 
to  a  cool  place,  his  clothes  removed,  and  external  cold  freely  applied. 
This  is  best  done  by  bodily  immersion  in  a  tub  of  water  of  a  tem- 
perature of  70°  or  80°  F.,  and  ice  added  so  as  rapidly  to  lower  the 
temperature  of  the  bath  as  the  case  may  require.  In  ordinary  cases  a 
temperature  of  the  bath,  attained  by  floating  ice,  of  40°  F.,  will  be 
found  necessary.  The  patient  should  be  kept  in  the  bath  until  the 
thermometer  in  the  mouth  or  rectum  has  fallen  to  about  101°  F.  or 
thereabouts,  and  the  surface  should  be  constantly  rubbed  while  in  the 
bath.  Usually  immersion  for  from  ten  minutes  to  a  half-hour  is  found 
requisite  to  attain  this  result.     After  removal  from  the  bath  the  tem- 


LEGAL    CONSIDERATIONS.  179 

perature  generally  falls  nearly  to  normal,  hut  in  the  course  of  an  hour 
or  two  it  rises  again.  The  same  process  should  then  be  re])eated. 
Constant  attention  to  the  patient's  temperature  is  necessary,  and  thcr- 
mometi-ic  records  should  be  taken  every  half-hour.  As  a  rule,  a  tem- 
perature of  102°  F.  or  over  should  be  regarded  as  an  indication  for  the 
bath  or  sponging  with  iced  water.  Even  after  some  hours  of  treatment 
a  tendency  to  paroxysms  of  fever  is  shown.  These  are  to  be  met 
promptlv  by  the  same  measures.  Sometimes,  if  meningeal  symptoms 
are  marked,  the  direct  ajiplication  of  ice  to  the  head  or  counterirritation 
at  the  nape  of  the  neck  may  be  of  value.  Occasionally  the  evidences 
of  cerebral  congestion  may  be  relieved  by  venesection,  but  the  greatest 
caution  in  the  selection  of  patients  for  this  measure  and  care  in  the 
amount  of  blood  abstracted  are  necessary  to  avoid  a  fatal  result.  The 
administration  of  antipyrin  and  other  similar  remedies  is  often  very 
beneficial,  and  the  hypodermic  administration  of  a  full  dose  is  to  be 
recommended  in  addition  to  the  foregoing  remedies,  \yhen  the  stage 
of  collapse  in  this  form  has  been  reached,  treatment  is  necessarily 
unavailing,  and  should  be  employed  as  outlined  in  ordinary  severe  heat 
collapse. 

I/Cgal  Considerations. — Death  from  heat-exposure  is  unknown 
in  homicide  or  suicide,  and  these  patients,  when  found  dead,  are  of 
interest  only  in  a  negative  sense.  The  absence  of  signs  of  violence,  the 
surrounding  circumstances  of  temperature  and  weather,  occupation  of 
the  individual  before  the  probable  attack,  together  with  the  described 
postmortem  appearances,  should  lead  to  at  least  a  strongly  probable 
opinion  as  to  the  cause  of  death.  In  case  of  insanity  and  criminal 
actions  without  the  usual  motive,  the  influence  of  previous  sunstrokes 
in  causing  cerebral  structural  changes  and  alienation  should  be  kept  in 
mind. 

(For  Burns,  Scalds,  and  Death  Therefrom,  see  page  333.) 

DEATH  FROM  STARVATION. 

Starvation  may  be  defined  as  the  result  of  total  or  partial  depriva- 
tion of  food.  Such  deprivation  must  be  understood  to  comprehend  the 
question  of  quality  as  well  as  quantity.  While  in  either  case  the  result 
must  be  the  same,  yet  from  a  clinical  standpoint  the  classification  of 
acute  starvation,  from  total  deprivation,  and  of  chronic  starva- 
tion, from  long-continued  partial  deprivation,  should  be  accepted.  Both 
forms  occasionally  may  be  the  subject  of  judicial  investigation  bearing 
on  questions  of  homicide,  neglect,  or  accident.  Criminal  employment 
of  this  means  of  destruction  is  a  comparative  rarity  before  courts  of 
justice,  yet  the  importance  of  questions  raised  in  such  })roccedings  and 
the  comparatively  frequent  suspicions  of  neglect  in  cases  of  death 
attended  by  great  emaciation  require  that  a  fairly  extended  considera- 
tion of  the  matter  be  made. 

A  food  may  be  defined  as  any  substance  which,  after  ingestion,  is 
capable  of  contributing  to  the  growth  or  repair  of  the  organism  or  to 


180  DEATH    FROM    STARVATION. 

the  development  of  energy  within  it.  The  main  elements  of  an  ordi- 
nary dietary  sufficient  to  maintain  normal  life  and  its  functions  include, 
in  somewhat  variable  proportions,  proteids,  carbohydrates,  fats,  inor- 
ganic salts,  and  water.  Of  these  the  proteids  are  efficient  mainly  in 
the  formation  of  the  protoplasmic  matter  required  in  the  growth  of  the 
mdividual  and  in  the  restoration  of  waste.  The  carbohydrates  and  fats 
are  concerned  mainly  in  tissue  breakdown  and  in  the  evolution  of 
energy,  principally  in  the  form  of  heat.  The  inorganic  salts  are  princi- 
pally of  use  in  their  participation  in  necessary  chemical  activities  in  the 
processes  of  nutrition,  and  they  likewise  contribute  in  a  measure  to  the 
structure  of  the  tissues.  Water  is  demanded  mainly  for  the  mainte- 
nance in  liquid  form  of  materials  brought  to  or  carried  from  the  dif- 
ferent vital  elements  of  the  body,  and  contributes  largely  to  the  constitu- 
tion of  these  cellular  elements.  Not  considering  the  water  and  salts 
for  the  moment,  although  it  has  been  shown  experimentally  that  life  in 
the  lower  carnivorous  animals  may  be  maintained  by  the  employment  of 
the  proteid  (nitrogen  l)earing)  foods  alone,  it  is  imjjrobable  that  a  healthful 
life  may  be  long  supported  in  man  by  this  single  class  of  food-stuifs. 
This  is  so  because  of  the  great  demands  required  in  digestion  and  assimi- 
lation and  by  the  great  increase  of  work  thrown  upon  the  excretory 
organs  in  order  to  eliminate  the  waste-products.  On  the  other  hand, 
both  experimental  and  clinical  observations  have  shown  that  normal 
animal  life  is  incapable  of  maintenance  m  ithout  jjroteids.  Either  fats 
or  carbohydrates  in  combination  with  proteids  are  capable  of  preserving 
the  nutritional  equilibrium  of  the  l)ody,  fats  being  weight  for  weight 
more  efficient  than  the  carbohydrates,  but  losing  somewhat  in  their 
efficiency  because  of  their  greater  difficulty  of  digestion.  The  true 
dietetic  regime  should,  therefore,  include  a  combination  of  all  three  of 
these  classes  of  material.  The  pro]iortion  of  such  combination  may 
vary  within  considerable  limits  ;  a  fair  proportion  is  that  of  Voit,  who 
places  the  ratio  of  nitrogenous  to  non-nitrogenous  foods  as  about  1  :  5, 
the  car])ohyd rates  largely  in  excess  of  the  fats  (10  :  1).  Following 
Voit's  estimation  of  the  requirements  of  an  adult  man  under  normal 
conditions  of  life  (proteids,  118  grams  ;  fats,  56  grams  ;  carbohydrates, 
500  grams),  one  may  roughly  estimate  such  requirements  for  a  period 
of  twenty-four  hours  as  about  a  pound  of  ordinary  fat  beef  and  two 
ordinary  one-pound  loaves  of  wheaten  bread  for  an  adult  male.  Com- 
monly the  safest  guide  for  the  determination  of  the  amount  supplied  is 
the  natural  sense  of  hunger,  carefid  estimates  of  the  different  varieties  of 
food  entering  merely  as  a  matter  of  interest,  and  occasionally  of  impor- 
tance in  the  dietetics  of  the  sick. 

From  the  foregoing  it  follows  that  dejirivation,  absolute  or  relative, 
may  be  an  efficient  cause  of  deleterious  results  both  in  the  total  amount 
of  food  and  in  the  elementary  character  of  the  same,  and  that  the  cause 
of  justice  may  be  concerned  not  only  in  cases  where  deprivation  is  total, 
but  where  it  is  systematically  partial  or  the  quality  restricted.  It  is 
impossible  in  the  space  of  the  present  article  to  discuss  the  nutritive 
value  of  the  various  food-stuffs,  and  Avhere  questions  arise  in  such  rela- 


DEATH    FKOM    STAEVATIOX.  181 

tious  reference  should  be  made  to  systematic  works  upon  dietetics  and 
plivsioloii'V. 

It  is  iiupu.-^sihle  to  state  the  lenu'tii  of  time  in  which  starvation  may 
produce  death,  since  many  nu)(hfyin^  circiunstaiices  may  occur  in  each 
instance.  D(;ath  lias  been  known  to  o(;cur  after  but  a  few  days'  total 
deprivation,  wliik'  there  is  reason  to  believe  that  total  deprivation  of 
ordinarv  food  may  sometimes,  if  water  be  allowed,  be  endured  for 
several  weeks,  a  month,  or  even  more.  The  case  of  Dr.  Tanner,  who 
fasted  publicly  for  forty  days,  drinkini;-  water  as  required,  may  be  cited 
in  support  of  such  statement,  although  the  credibility  of  the  genuineness 
of  total  deprivation  is,  it  cannot  be  denied,  frecpiently  questioned. 
AVell-authenticated  cases  of  deprivation  of  all  foods,  water  included,  are 
recorded,  in  \vhich  recovery  follow(Ml  after  starvation  for  nine  to  twelve 
days.  The  allowance  of  water  to  animals  experimentally  starved  may 
prolong  life  to  double  the  duration  possible  without  it ;  and  in  the 
experience  of  starving  human  beings  a  similar  protracting  influence  has 
been  noted.  When  dejirivation  is  incomplete  in  other  substances  besides 
Avater,  the  duration  of  life  is  very  iudefinite,  and  cannot  be  estimated 
without  (Consideration  of  the  actual  degree  of  ileprivation  and  the  per- 
sonal peculiarities  of  the  case. 

The  period  of  life  best  suited  for  resisting  starvation  is  that  of  full 
development — /.  c,  early  manhood  or  womanhood.  Starvation  of  infants 
is  apt  to  terminate  fatally  as  early  as  the  second  or  the  third  day  of 
deprivation  ;  and  the  aged  are  likewise  likely  to  succuiub  in  the  course 
of  several  days.  The  state  of  nutrition  at  the  beginning  of  the  fast  is 
of  material  influence  upon  its  possible  duration,  the  fat  stored  up  in  the 
body  being  drawn  upon  as  food  for  its  maintenance.  Females,  there- 
fore, on  account  of  their  relatively  greater  adipose  deposit,  are  liable  to 
withstand  starvation  for  a  longer  period  than  males.  The  loss  of  energy 
through  physical  exertion,  as  seen  in  the  endeavors  of  starving  persons 
to  reach  places  of  relief,  materially  diminishes  the  time  when  a  fatal 
termination  may  be  expected.  Low  degrees  of  surrounding  temperature 
also  accelerate  the  oncome  of  death  ;  high  surrounding  temperatures,  on 
the  contrary,  are  not  protective,  but  also  accelerate,  unless  a  sufficient 
amount  of  water  is  available.  Moderate  warmth,  hoAvever,  favors  the 
continuance  of  life,  and  the  possession  of  sufficient  clothing  has  more 
than  once  been  the  means  of  saving  human  life  in  periods  of  temporary 
deprivation.  Chossat  first  called  attention  to  the  fact  that  in  experi- 
ments upon  animals,  when  the  temjierature  has  fallen  as  low  as  76.8° 
F.,  death  usually  occurs,  a  tem])erature  commonly  lethal  in  cases  of 
refrigeration,  and  it  has  been  inferred  that  the  loss  of  body-temperature 
in  privation  bears  some  causal  relation  to  the  death.  Diseases  which 
have  impaired  the  nutrition  of  the  patient,  pathologic  conditions  inter- 
fering with  alimentation,  chronic  wasting  diseases — all  exert  an  unfavor- 
able influence  upon  the  powers  to  resist  the  efl'ects  of  starvation,  and  are 
frequently  the  actual  causes  of  the  starvation.  Various  chroni<'  drug- 
habits — alcoholism,  morjiliinism,  cocainism,  etc. — by  their  interference 
with  the  alimentary  functions,  lead  to  greater  or  less  imj)airment  of 


182  DEATH    FROM    STARVATION. 

nutrition,  and  may,  therefore,  be  considered  as  predisposing  states  to  the 
final  effects  of  incidental  starvation.  It  is  not  unusual,  in  the  rare 
instances  in  which  privation  is  employed  purposely  to  destroy  life,  that 
other  forms  of  ill  treatment  should  also  have  been  practised  upon  the 
victim.  Violence,  exposure  to  extremes  of  temperature  or  inclemencies 
of  the  weather,  permission  of  filth  accumulation  with  all  its  attendant 
miseries,  harsh  moral  influences — all  may  have  combined  to  render  the 
waning  life  of  the  sufferer  more  horrible,  and  neglect  of  attention  to 
intercurrent  or  consequent  ills  may  materially  hasten  the  close  of  the 
case. 

Symptoms. — The  sense  of  hunger,  after  manifesting  itself  a  few 
hours  after  partaking  food,  becomes  more  and  more  urgent  for  forty- 
eight  or  seventy-two  hours  and  then  gradually  lessens  in  intensity, 
the  desire  for  food  being  almost  entirely  lost  in  many  cases  of  well- 
advanced  acute  starvation.  An  uncomfortable  sensation  in  the  epigas- 
trium is  usually  felt.  The  intellect  often  remains  unclouded  throughout 
the  duration  of  the  case  until  just  before  death,  when  coma  usually 
ensues ;  in  other  cases,  after  a  day  or  two  of  great  restlessness,  the 
patient  becomes  calm,  quiet,  even  lethargic,  until  near  the  end,  when 
restlessness  may  again  supervene  before  the  coma  develops.  Emacia- 
tion is  the  most  prominent  objective  symptom,  the  greatest  loss  of 
weight  taking  place  during  the  early  part  of  the  period  of  privation. 
Eventually  it  is  apt  to  become  extreme ;  the  muscles  and  fat  waste 
away  until  the  skin  hangs  loosely,  and  the  bones  stand  out  prominently 
as  if  covered  only  by  the  skin.  The  greatest  loss  of  weight  occurs  by 
the  absorption  of  the  fat  from  every  situation  of  its  deposit,  and  by 
great  diminution  of  the  musculature ;  but  some  diminution  may  be  met 
also  in  nearly  every  soft  part  of  the  body.  The  eyes  are  sunken  from 
loss  of  the  orbital  fat,  and  the  face  is  ghastly  and  thin.  The  skin 
becomes  dry,  harsh,  and  often  bronzed.  The  tongue  is  thickly  furred, 
and  the  mouth  and  throat  are  dry.  One  or  two  defecations  at  the 
beginning  of  the  case  are  normal,  but  then  become  small  and  infrequent 
until  just  before  death,  when  a  colliquative  diarrhea  may  set  in.  The 
urine  rapidly  becomes  scant  and  of  high  color,  often  containing  a  small 
amount  of  albumin.  The  respirations  rapidly  become  more  and  more 
shallow,  Avenk,  and  frequent.  The  pulse  becomes  small,  weak,  and 
either  very  rapid  or  very  slow.  The  loss  of  physical  strength  is 
greatest  in  the  first  few  days,  but  is  gradually  progressive  throughout 
the  case,  and  becomes  extreme  with  the  terminal  diarrhea.  A  peculiar, 
disagreeable,  mouse-like  odor  arises  from  the  patient  and  pervades  the 
apartment.  The  pupils  are  usually  moderately  dilated,  and  the  con- 
junctiva? are  blood-shot.  The  patient  complains  of  great  dizziness,  and 
trembles  upon  the  slightest  exertion.  Sometimes,  in  advanced  cases, 
just  before  death,  hallucinations  and  dreams  of  feasting,  sometimes 
actual  insanity  with  well-marked  delusions,  may  come  on.  Death  from 
a  gradual  failure  of  the  heart  finally  occurs  while  the  patient  is  uncon- 
scious ;  occasionally  slight  spasms  terminate  the  case.  This  acute  form 
of   starvation   begins    suddenly,   from   accidental   privation,   as   in   the 


POSTMORTEM    APPEARANCES.  183 

entonibiuent  of  miners,  the  wreck  of  a  vessel,  the  occurrence  of  a 
dchision  denuuidiiit;-  abstinence  from  food  in  the  insane,  or  deliberate 
withdraM^al  of  lood  by  those  in  chart;e  of  some  unfortiniate  individual. 

The  chronic  form  occurs  in  famine  from  various  causes — in  those 
possessing  some  grave  lesion  of  the  nutritive  ap})aratus,  as  a  cancer  of 
the  esophagus  or  stomach ;  in  chiidi'en  in  charge  of  ignorantly  oi*  per- 
versely careless  nurses;  or  in  the  hclj)less  insane  under  similarly 
inefficient  caretakers.  Here  the  course  of  the  case  is  usually  nuich 
more  j)rotracted,  months  frequently  intervening  from  the  first  privation 
to  death  ;  but  the  symptoms  are  similar  to  those  of  the  acute  form. 
These  are  :  Loss  of  strength  and  weight,  which  are  marked  and  pro- 
gressive, with  emaciation,  cadaveric  countenance,  pallor,  thinning  and 
darkening  of  the  skin,  feebleness  of  respiration  and  circulation,  dry, 
furred  tongue,  constipation,  diminished  acid  urine,  restlessness,  j^eevish- 
ness,  tremor,  and  dizziness.  The  intellect,  as  in  acute  starvation,  may 
remain  for  the  most  part  clear  until  near  the  lethal  stage,  when  stupor, 
delirium,  or  coma  generally  appear.  Hallucinations,  phantasms,  and 
actual  insanity  may  develop.  Often  in  these  protracted  cases  the  blood 
is  seriously  altered  and  purpuric  eruptions  apjiear,  lending,  at  least 
toward  the  close  of  the  case,  a  superficial  similarity  to  scurvy.  In 
both  acute  and  chronic  starvation  the  temperature  tends  to  fall.  Large 
diurnal  variations  between  mc^rning  and  evening  records  are  common. 
As  low  a  registration  as  75°  or  70°  F.  may  be  reached  before  death. 
The  rapidity  of  loss  in  strength  and  of  emaciation,  as  well  as  of  the 
development  of  the  other  symptoms,  is  dependent  upon  the  relative 
degree  of  privation,  but  the  extreme  manifestations  to  be  met  in  either 
form  are  the  same.  This  loss  of  weight  is  less  marked  in  infants  or  in 
those  weak  from  disease  or  age,  who  succumb  before  the  emaciation 
becomes  extreme  ;  but,  as  a  rule,  as  much  as  30  or  40  per  cent,  of  the 
body-weight  is  lost  before  death.  Death  generally  occurs  from  asthenia 
or  syncope,  or,  as  in  the  acute  form,  spasms  may  end  the  miserable 
scene. 

Postmortem  Appearances. — The  body  usually  presents  a 
squalid  ajipearance,  and  the  peculiar  odor  previously  mentioned  per- 
sists. The  skin  is  thin,  often  ulcerated  or  excoriated.  It  has  a  dirty 
brownish  appearance.  This  tint  is  widely  distril)uted,  but  varies  in  hue 
in  different  parts,  and  is  apparently  the  result  of  the  persistence  of 
the  dead,  dry  epithelium.  Bed-sores  are  frecpient.  The  emaciation  is 
extreme  ;  and  in  many  cases  every  evidence  of  neglect,  from  marks  of 
brutal  violence  to  the  infestment  by  vermin,  may  be  at  hand.  The 
eyes  are  sunken,  dry,  and  generally  injected.  The  mucous  membranes 
are  ]iale,  and  the  tongue  is  dry  and  coated. 

The  body  being  opened,  the  abseiu^e  of  the  ordinary  fat  de])osit 
beneath  the  skin,  in  the  omentum,  and  in  the  other  usual  situations  is 
most  striking.  The  muscles  are  small  and  ])ale ;  the  stomach  and 
intestines  are  contracted,  the  contraction  being  generally  more  marked 
in  some  portions  than  in  others.  These  viscera  are  usually  empty. 
The  mucous  membrane  of  the  stomach  and  upper  part  of  the  bowel  is 


184  DEATH    FROM    STARVATION. 

diffusely  stained  with  bile.  The  walls  of  these  viscera  are  thin,  the 
wasting  making  them  almost  transparent  in  extreme  cases.  Should  the 
bowels  retain  any  of  their  contents,  such  are  generally  found  in  the 
lower  bowel  as  hard,  scybalous  masses.  Often  the  lower  portion  of  the 
large  bowel  will  present  more  or  less  evidence  of  intiammatiun.  There 
are  no  important  changes  in  the  kidneys,  liver,  spleen,  or  pancreas,  save 
possibly  a  moderate  diminution  in  size  and  increased  depth  of  color 
from  congestion.  The  gall-bladder  is  apt  to  be  distended  with  dark, 
fluid  l)ile.  The  heart  is  connnonly  somewhat  diminished  in  size,  and  its 
epicardial  surface  is  pale  and  loose.  The  diminution  in  weight  of  this 
organ  is  not,  however,  in  the  writer's  experience,  proportionate  to  the 
wasting  in  the  remainder  of  the  muscular  system.  There  is  but  little 
blood  in  the  heart,  and  that  in  the  right  side  is  dark  and  fluid.  The 
heart  muscle  is  pale  and  flabby.  The  lungs  are  usually  pale,  somewhat 
edematous,  and  present  hypostatic  areas  of  congestion  at  the  base.  Tiie 
meningeal  venous  vessels  are  frequently  full  of  blood  ;  there  is  often 
some  excess  of  serous  effusion  in  the  meninges  and  ventricles  ;  the  brain 
substance  is  generally  pale  and  soft. 

In  the  examination  of  the  body  of  a  person  suspected  of  having 
died  from  starvation  the  following  questions  should  be  inquired  into  in 
order  that  the  evidence  before  the  court  may  be  fair  and  sufficient  for 
the  questions  possibly  arising:  (1)  Are  the  usual  appearances  of  death 
from  starvation  present  in  the  body  examined  ?  (2)  Are  there  evidences 
of  the  existence  of  other  disease  present?  (3)  If  the  latter  is  the  case, 
could  such  disease  have  given  rise  to  the  apjiearances  of  starvation  or  to 
the  starvation  itself?  (4)  Could  such  disease  have  materially  influenced 
the  course  of  ordinary  starvation  ?  (5)  Are  there  reasons  to  believe  that 
the  deprivation  of  food  could  have  caused  the  lesions  of  such  other  dis- 
covered disease,  or  could  it  have  seriously  complicated  the  course  of 
such  affection  ?  (0)  What  relation  do  the  antemortom  symptoms,  as 
known  or  elicited  by  legal  inquiry,  bear  to  the  ])robability  of  death  by 
starvation  or,  by  other  discovered  disease  ?  Such  questions  necessitate 
not  merely  the  recognition  of  the  postmortem  signs  already  indicated, 
but  likewise  require  of  the  physician  in  his  autopsy  to  seek  carefully  for 
the  existence  of  any  disease  that  might  explain  the  signs  of  inanition 
upon  a  natural  ground,  and  for  the  existence  of  complications  which 
may  have  influenced  the  course  of  the  case.  The  whole  alimentary  tract 
and  its  associated  viscera  should  be  examined  for  the  existence  of 
malignant  tumors,  strictures,  serious  inflammations,  compressions,  or 
atrophies.  Tlie  possible  existence  and  influence  of  wasting  diseases, 
such  as  tul)erculosis,  diabetes,  Addison's  disease,  or  the  severe  anemias, 
must  be  considered,  and  a  careful  attention  given  to  the  possible  rela- 
tions of  the  entire  symptom-complex  with  such  diseases.  In  addition  to 
these  points  the  usual  care  in  noting  the  ordinary  medicolegal  featui'es 
in  and  al)out  the  dead  l)ody  must,  of  course,  be  followed. 

Treatment. — The  main  indication  in  the  eftbrts  toward  restoration 
of  those  dvinsj;  from  starvation  is  the  administration  of  nutritious  mate- 
rial.     Caution  should  be  observed,  however,  in  every  such  administra- 


DEATH    l'i:c)il    THIIIST.  185 

tion,  since  the  least  excess  is  likely  to  be  followed  by  serious  reaction, 
even  death.  Only  small  amounts  of  food  should  be  given  at  a  time  to 
such  a  ])nti(M)t,  the  adiniuistration  repeated  at  frequent  intervals,  an<l 
great  care  observed  to  provitle  only  the  simplest  and  most  easily  digested 
substances.  Milk  is  very  valuable  for  such  purposes,  and  the  concen- 
trated and  partly  digested  food-[)reparations  are  likewise  of  great  effi- 
ciency. For  a  time  all  food  sliould  be  fluid,  and  be  administered  hot. 
The  addition  of  solid  foods  should  l>e  made  gradually  aud  with  eiire,  the 
readiness  of  digestion  and  nutritive  value  being  considered.  Failure  to 
attend  to  such  cautions  may  be  followed  rapidly  by  death,  probably 
from  vasomotor  disturbances  reflexly  aroused  by  the  presence  of  the 
large  mass  in  the  stomach.  Stimulants  may  be  administered  with 
benefit,  care  being  taken  that  they  should  be  given  in  small  amounts 
and  in  dilute  form  if  administered  by  the  mouth.  When  possible, 
they  are  best  given  hypodermieally.  All  substances  given  by  the 
natural  tract  should  be  warm,  so  as  to  aid  in  digestion  and  diffusion 
and  at  the  same  time  contribute  heat  for  the  readjustment  of  the 
depressed  body-temperature.  So,  also,  the  application  of  external  heat 
and  rubbing  the  surface  with  warming  lotions  to  cause  the  return  of 
the  superficial  circulation  should  be  emploved. 

I/Cg-al  Considerations. — From  the  standpoint  of  the  physician 
little  need  be  added  to  the  cautions  already  indicated  in  the  performance 
of  the  autopsy.  It  should  be  recalled,  however,  that  in  determination 
of  death  from  starvation  the  sole  judicial  question  does  not  concern  the 
absolute  withdrawal  of  food  from  the  victim,  but  that  there  is  reason 
for  legal  inquiry  also  where  the  partial  privation  of  quantity  or  quality 
has  caused  or  has  been  contributory  to  death.  And  so,  also,  the  matter 
of  motive,  in  long-continued,  systematic  partial  starvation,  as  may  be 
practised  upon  weaklings  to  their  eventual  death,  is  as  much  a  question 
for  judicial  consideration  as  the  wilful  and  total  deprivation  of  food. 
In  the  establishment  of  such  motive  and  its  legal  bearing,  questions  of 
interest,  ignorance,  and  superstition  are  to  be  fairly  considered,  in  ^vhich 
inquiries  the  evidence  as  to  coincident  ill  treatment  of  the  victim  in  other 
matters  than  in  the  provision  of  food  should  be  duly  weighed. 

THIRST. 

The  deprivation  of  water  is,  in  reality,  like  the  deprivation  of 
other  foods,  a  f  )rm  of  starvation.  The  deprivation  of  water  is  almost 
invariably  accidental  and  surrounded  by  such  eii-cumstances  as  to 
obviate  the  necessitv  for  careful  legal  investio-ation.  Heat  of  the 
surrounding  atmosphere,  character  of  the  climate,  and  the  physical 
energy  used  in  the  efforts  to  reach  water  all  contribute  largely  to  the 
rapidity  of  development  and  intensity  of  results  of  deprivation  of 
fluid.  The  desire  for  water  (piiekly  becomes  overpowering,  the  saliva 
disappears,  the  throat  and  the  tongue  become  dry  and  swollen,  and  the 
sensation  of  taste  disappears  ;  swallowing  of  other  food  becomes  impos- 
sible.    The  skin  is  dry  and  hot,  later  becoming   pale    and  shriveled. 


186  DEATH    FROM    THIRST. 

Muscular  power  diminishes  rapidly ;  vertigo  and  dimness  of  vision, 
feebleness  of  voice,  diminution  of  urine,  restlessness,  insomnia,  hallu- 
cinations, and  insanity  may  all  develo]).  Death  takes  place  usually  in 
four  or  five .  days,  at  the  utmost,  in  able-bodied  males,  a  much  shorter 
period  being  required  in  less  vigorous  individuals.  After  death  the 
body  is  wasted,  the  surface  pale,  shriveled,  and  dry,  the  eyes  are 
sunken,  and  the  mucous  membranes  are  pale  and  cracked ;  the  blood  is 
firmly  clotted,  the  viscera  are  congested  but  not  swollen,  and  the  mus- 
culature and  fat  are  much  wasted. 

In  the  restoration  of  those  dying  from  thirst  the  irritability  of  the 
gastric  mucous  membrane  and  the  vascular  inertia  to  sudden  shock  must 
be  kept  in  mind  ;  and  liquids  should  be  given  only  in  small  amounts 
and  preferably  heated.  The  symptom  of  thirst  should  not  be  heeded 
in  such  cases,  as  it  is  of  central  origin  and  is  not  appeased  until  the 
entire  system  has  received  the  benefits  of  restoration  of  fluid  ;  and  it  is 
well  known  that  if  left  to  themselves,  men  dying  of  thirst  are  likely 
to  die  after  overloading  their  stomachs  with  water,  which  is  promptly 
vomited,  and  the  patient  is  but  rendered  the  weaker  for  the  eiforts  at 
retchii\g.  Hot  coffee  in  small  quantities  at  a  time  and  dilute  aifords. 
the  best  measure  for  immediate  use,  the  stimulant  action  of  the  coffee 
increasing  the  flagging  circulation  and  causing  more  rapid  absorption 
and  diffusion  of  the  liquid. 


DEATH  FROM  ASPHYXIA. 


Definition. — By  the  term  asphyxia  is  meant  the  fatal  or  deleterious 
result  of  any  interference  with  the  normal  processes  of  respiration. 
Respiration  in  each  of  its  divisions  of  inspiration  ttnd  expiration  is  a 
three-fold  act.  Inspiration,  for  example,  includes  the  entrance  of 
atmospheric  air  along  the  respiratory  passages  to  the  pulmonary  alveoli, 
the  diffusion  of  its  oxygen  through  the  animal  structures  separating  it 
from  the  blood  and  combination  with  the  latter,  the  convection  of  the 
oxygen  to  the  cellular  elements  of  the  body  and  its  transference  to 
these.  Expiration  is  the  expression  of  the  reverse  phenomena  result- 
ing in  the  elimination  of  carbon  dioxid.  Each  of  these  is  physio- 
logically divisible  into  an  external  and  an  internal  process,  the  passage 
of  the  gases  in  question  through  the  walls  of  the  pulmonary  vessels  and 
air-spaces  marking  the  separation  between  these  divisions.  The  process 
of  asphyxiation  may  therefore  be  technically  understood  to  include  any 
interferences  with  the  passage  of  properly  oxygenated  air  along  the 
respiratory  tracts,  the  prevention  of  the  lungs  to  receive  such  air  enter- 
ing by  these  passages,  and  any  interference  with  the  proper  power  of 
the  blood  to  combine  with  and  convey  oxygen  or  carbon  dioxid  to  or 
from  the  tissues.  Further,  although  of  little  concern  in  the  scope  of 
the  present  discussion,  alterations  of  the  nervous  apparatus  presiding 
over  the  function  of  respiration  should  not  be  neglected  from  a  purely 
technical  point  of  view. 

It  is  clear,  however,  that  our  ordinary  ideas  of  asphyxiation  do  not 
embrace  all  these  possibilities.  For  example,  the  convection  of  oxygen 
by  the  blood  may  have  been  prevented  by  circulatory  failure  ;  and  while 
the  term  asphyxia  (a,  absence  of;  acp'j^iz,  pulse)  was  originally  intended 
to  indicate  tiiis  very  condition,  such  meaning  is  no  longer  held  either 
popularly  or  generally  by  the  medical  profession.  So,  also,  the  various 
interferences  with  the  intricate  processes  of  cellular  respiration,  or  of 
the  relatively  unimportant  skin  rcs]iiration,  are  not  to  be  regarded  as 
essential  portions  of  the  meaning  of  the  term  in  its  ordinary  sense.  On 
the  other  hand,  the  results  of  the  inhalation  of  a  number  of  noxious 
gases  with  great  propriety  could  be  grouped  rather  with  the  intoxicants 
than  with  the  asphyxiating  agents,  althougli  by  consent  and  without 
impropriety  they  are  usually  discussed  with  the  latter. 

Therefore  Avith  these  considerations  in  view  and  for  the  ]iurpose  of 
limiting  the  definition  to  the  convenience  of  legal  inquiry,  asjihyxia  may 
be  stated  to  include  merely  the  general  results  of  mechanical  interfer- 

187 


188  DEATH    FEOM    ASPHYXIA. 

ence  with  the  entrance  and  exit  of  air  to  the  hmgs  and  the  prevention 
of  interchange  of  the  respiratory  gases  between  the  pulmonary  air-spaces 
and  the  blood. 

Within  the  limits  of  such  a  definition  death  from  asphyxia  may  be 
considered  as  embracing  death  from  strangulation,  death  from  choking, 
and  death  from  suifocation,  including  intoxication  by  certain  deleterious 
gases.  Much  latitude  is  permitted  in  the  use  of  these  terms  by  modern 
lexicographers,  but  in  the  present  discussion  they  are  employed  with 
definite  significance.  By  the  term  strangulation  is  meant  to  be  under- 
stood the  interference  of  the  passage  of  air  to  the  lungs  by  external 
compressing  force  aj^plied  to  the  throat  or  neck,  as  in  hanging  or  throt- 
tling. Choking  should  be  understood  as  applying  in  those  cases  in  which 
interference  with  respiration  has  resulted  from  obstructing  agencies 
within  the  air-passages,  such  as  foreign  bodies,  false  membranes,  stric- 
tures or  tumors  of  the  air-passages  ;  or  the  presence  of  neutral  or  irri- 
tating gases  or  fluids  interrupting  the  movement  of  the  resjiiratory  air 
to  or  from  the  hmgs  mechanically  or  by  producing  spasmodic  constric- 
tion of  the  walls.  The  term  suffocation  may  be  employed  to  include 
all  mechanical  influences  applied  externally  elsewhere  than  about  the 
throat  in  the  prevention  of  respiration  ;  and  may,  for  convenience,  be 
required  to  include  the  results  of  those  agents  which,  through  their  toxic 
influence  upon  the  blood,  render  it  unfit  for  convection  of  the  respira- 
tory gases.  In  this  sense  suffocation  would  be  properly  applied  in  such 
cases  in  which  the  mouth  and  nostrils  are  closed  by  some  external  sub- 
stance, as  a  ])illow  or  a  mass  of  nuid  (often  spoken  of  as  smothering), 
where  the  resjiiratorv  movements  are  prevented  by  the  pressure  of  a 
crowd  or  weight  ujion  the  chest ;  or  where,  as  in  ])oisoning  by  carbon 
monoxid  gas,  the  henidglobin  of  the  I'ed  blood-cells  is  no  longer  able 
to  enter  into  combination  with  the  oxygen  of  the  air  or  carbonic 
dioxid  of  the  tissues.  Moreover,  here  should  l)e  classified  the  rare 
cases  of  respiratory  prevention  from  raretaction  of  the  surrounding 
atmosphere  and  confinement  in  a  close  space.  It  is  unfortunate  that 
clearer  definition  of  the  various  terms  ap})lied  does  not  exist,  the  con- 
fusion having  probably  arisen  with  the  gradually  appreciated  insuf- 
ficiencies of  the  Avords.  Thus  the  term  "  choke, ^'  from  its  etymologic 
relation  with  the  words  "  cheek "  and  "  chew,''  was  evidently  at  first 
applied  to  obstructions  occurring  in  the  mouth  or  upper  part  of 
the  throat ;  while  the  word  "  suffocation "  seems  to  have  been  later 
applied  to  instances  of  respiratory  failure  arising  from  causes  operative 
below  the  level  of  the  fauces  {suh,faux,  -cis).  These  original  meanings 
having  little  value  in  the  present  state  of  our  information,  there  is  no 
necessity  in  trying  to  resuscitate  them  ;  and  it  seems  better  to  attempt 
to  define  the  terms  according  to  the  prevailing  ideas,  even  though  such 
definitions  are  somewhat  artificial. 

General  Features  of  Asphyxiation. — Asphyxiation  may  occur 
either  gradually  or  with  greater  or  less  suddenness.  Gradual  as])hyx- 
iation  is  commonly  encountered  in  natural  death  from  various  dis- 
eases, while  the  rapid  form  is  met  either  in  death  from  disease  or  in 


GENERAL    FEATURES    OF    A.Sl'IIYXIATroX,  189 

accidental  or  purposeful  death.  The  gradual  oncoine  of  asphyxia,  which 
may  occasionally  give  rise  to  legal  questions  in  eireunistances  of  death 
from  confinement  in  insuHieient  close  space,  is  niai'ked  by  a  general 
sense  of  discomfort,  muscular  weakness,  nausea,  headache,  profuse  per- 
spiration, lividity  of  surface,  rapid  or  slow  weak  pulse,  labored  respira- 
tion, loss  of  consciousness,  development  of  anesthesia,  death,  the  heart- 
beats persisting  for  an  apj)reciable  period  after  respirations  have  ceased. 
When  the  cause  of  aspliyxia  is  most  sudden,  as  is  usual  in  legal  cases, 
there  is  immediately  after  the  a]>])lication  of  the  asphyxiating  cause  a 
brief  period  of  quiet,  lasting  only  for  some  seconds,  the  time  the  indi- 
vidual is  able  voluntarily  to  suspend  breathing  ;  then  more  or  less 
violent  eflForts  are  made  for  several  minutes  to  recover  air,  after  which 
unconsciousness  and  insensibility  come  on  and  the  respiratory  eiForts 
grow  more  and  more  feeble.  Finally  all  respiratory  movements  are 
stopped  after  several  minutes  more,  the  heart-beats  continuing  a  minute 
or  two  longer.  Death  is  not  regarded  as  having  occurred  until  all 
cardiac  pulsation  has  ceased,  and  it  is  possible  to  resuscitate  the  victim 
at  any  period  until  cessation  of  circulation  has  taken  place.  The  coun- 
tenance usually  becomes  livid  and  cyanosed,  the  eyes  are  prominent  and 
widely  staring,  and  there  are  a  sense  of  fulness  to  bursting  in  the  head, 
roaring  in  the  ears,  and  dizziness ;  for  a  moment  thoughts  and  recol- 
lections of  a  lifetime  crowd  in  upon  the  mind,  and  then  quickly  die 
away  into  unconsciousness.  The  whole  process  may  be  completed  in 
the  course  of  four  or  five  minutes,  or  may  be  protracted  for  two  or 
three  times  as  long.  Occasionally  asphyxia  terminates  life  almost 
instantly. 

Variations  in  the  period  requisite  to  destroy  life  may  depend  u]>on 
such  factors  as  age,  constitution,  degree  of  oxygenation  of  the  blood  at 
the  beginning  of  the  process,  and  the  degree  of  prevention  of  respira- 
tion, as  well  as  the  implication  of  the  nervous  system  and  circulatory 
apparatus  by  the  active  cause.  Thus  newly  born  infants  may  fail  from 
several  causes  to  breathe  for  a  number  of  minutes  after  birth,  and  in 
fatal  cases  of  congenital  asphyxia  pulsations  in  the  funis  may  persist 
for  fifteen  or  twenty  minutes.  Vigorous  individuals  and  those  pos- 
sessing unim])aired  circulatory  and  nervous  apparatus,  as  a  rule,  endure 
asphyxiation  for  a  longer  time  than  the  weak  and  ill,  although  the  dif- 
ference is  rarely  great.  Yet  such  a  feature  sliould  be  thought  of  in 
cases  involving  inheritance  by  order  of  death,  several  persons  dying 
from  asphyxiation  under  the  same  conditions  and  together  (see  chapter 
on  Sudden  Death).  The  first  period  of  asj)hyxiation  may  be  length- 
ened, although  to  an  unimportant  degree,  by  the  fict  that  inniiediately 
prior  to  the  stoppage  of  breathing  the  blood  had  lieen  well  oxygenated 
by  a  number  of  strong,  full  inspirations  ;  or,  on  the  other  hand,  may  be 
shortened  if  the  respirations  just  preceding  stoppage  have  been  incom- 
plete. 

The  length  of  time  required  in  gradual  asphyxia  from  confinement 
in  close  quarters  cannot  well  be  in(.licated,  inasmuch  as  it  is  entirely 
dependent  upon  the  amount  and  purity  of  the  confined  atmosphere  at 


190  DEATH    FROM    ASPHYXIA. 

the  time  of  inclosure,  the  permeability  of  the  inclosing  walls  to  air,  and 
the  rapidity  of  oxygen  consumption  by  the  individual — this  last  factor 
resting  upon  the  size  of  the  person  and  the  rate  and  fulness  of  respira- 
tion as  determined  by  muscular  effort  or  quiet,  by  health  or  disease,  etc. 
In  estimating  the  time  in  any  particular  instance  it  should  be  remem- 
bered that  an  average  human  adult  will  vitiate  for  continued  breathing 
about  175  cubic  feet  of  air  an  hour,  and  that  double  the  degree  of  such 
vitiation  may  give  origin  to  fatal  asphyxiation. 

While  there  are  some  special  differences  in  the  postmortem  appear- 
ances in  the  different  forms  of  death  by  asphyxiation,  in  general  there 
is  considerable  uniformity.  Usually  there  is  lividity  of  the  surface, 
especially  about  the  face  and  upper  extremities  ;  the  right  side  of  the 
heart  is  engorged,  the  blood  dark  and  uncoagulated,  the  various  viscera 
are  congested,  and  occasionally  there  are  small  patches  of  hemorrhage 
in  different  situations  from  the  excessive  passive  engorgement.  There 
are  various  local  signs,  differing  according  to  the  mode  of  asphyxiation, 
which  are  to  be  sought  for  as  evidences  of  the  particular  manner  of  pro- 
duction ;  and  both  general  and  local  signs  are  subject  to  variation  by  a 
number  of  possible  factors.  In  the  examination  of  a  body  dead  from 
asphyxiation,  in  addition  to  the  recognition  of  the  general  mode  of 
death,  constant  and  great  care  is  to  be  exercised  in  the  discovery  of 
such  evidence  as  may  be  given  by  the  body  and  the  surroundings  upon 
the  particular  mode  of  production  ;  and  the  coexistence  of  pathologic 
conditions  capable  of  causing  death  naturally  by  asphyxia  and  the 
careful  estimation  of  their  importance  and  influence  are  questions  cer- 
tain to  arise  in  any  legal  proceedings  upon  the  subject. 


I.  DEATH  BY  STRANGULATION. 

Death  by  strangulation  is  the  fatal  result  of  compression  of  the 
fauces,  larynx,  or  trachea  by  any  force  externally  applied  to  the  neck. 
While  such  cases  do  not  properly  belong  here,  in  this  category  are  also 
included  cases  dead  from  nervous  or  circulatory  lesions  produced  in  the 
attempt,  as  may  occur  in  hanging,  where  apoplexies  from  compression 
of  the  veins  of  the  neck  or  serious  mechanical  injury  to  the  cervical 
cord  from  "  breaking  the  neck  "  are  not  infrequent.  This  form  of  pro- 
ducing asphyxiation  includes  those  cases  where  throttling  by  the  hand 
and  conq:)ression  by  some  encircling  band  about  the  neck,  as  the  garrote 
of  the  Spanish,  the  bowstring  of  the  Turks,  or  a  cord  or  cloth,  as  used 
by  the  thugs  of  India,  have  been  the  methods  of  destruction,  as  well  as 
hanging,  where,  the  neck  being  partially  or  completely  encircled  by  a 
band  suspended  from  a  superior  fixed  point,  the  weight  of  the  victim's 
body  is  in  more  or  less  suspension. 

I.  Death  by  Throttling. — Throttling  by  the  hand  is  practically 
always  a  criminal,  murderous  form  of  asphyxiation.  It  is  not  absolutely 
impossible  that  violent  application  of  the  victim's  hand,  even  for  a  brief 
time,  to  the  throat,  as  possibly  in  paroxysms  of  epilepsy  or  hysteria, 
might  give  rise  to  fatal  after-effects  or  be  immediately  fatal ;  but  such 


DEATH    I?Y    THROTTLING.  191 

cases  are  practically  unknown.  Imch  where,  in  such  cases,  the  hand 
is  found  ai)i)lied  to  the  throat  and  hfuise-marks  from  the  force  of  the 
constriction  are  evident,  rarely  can  these  be  regarded  as  of  particular 
importance,  since,  as  a  rule,  throttling  requires  a  continuous  force  for 
some  minutes  at  least — almost  an  impossibility  under  any  circumstances 
in  the  situation  in  question  by  the  victim  himself.  When  strangulation 
of  this  variety  is  accomplished  by  means  of  a  constricting  band,  it  is 
usually  a  purposeful  act  of  destruction  by  an  individual  other  than  the 
victim,  but  instances  of  suicide  by  throttling  in  tiiis  way  are  common. 
Accidents,  the  result  of  foolish  constriction  of  the  neck  and  from  ex- 
cessively tight  clothing,  have  occasionally  occurred.  Strangulation  by 
throttling  from  the  pressure  of  some  hard  substance  against  the  throat 
is  not  unknowai.  In  such  instances  a  person  has,  perhaps,  fallen  sense- 
less or  stumied  and  lies  witli  the  throat  across  the  edge  of  a  board  or 
rock,  or  some  unyielding  material  of  moderate  weight  has  in  some  way 
been  placed  across  the  front  of  the  neck  of  an  unconscious  person.  Some- 
times, where  a  band  is  applied  about  the  neck  of  the  victim  for  the  pur- 
pose of  murder,  a  knot  in  the  ligature  or  a  stone  in  the  folds  of  the  cloth 
is  adjusted  directly  over  the  wdndpijie,  in  order  that  the  compression  of 
tlie  walls  of  this  passage  may  be  more  thoroughly  accomplished  in  the 
act  of  constriction. 

In  throttling  by  the  hand  one  or  both  of  the  murderer's  hands  are 
applied  to  the  front  of  the  throat,  grasping  and  compressing  the  trachea, 
larvnx,  or  the  upper  liorder  of  the  latter.     When  both  hands  are  used, 
frequently   the   application   is   such   as   to   bring   both    thumbs   of   the 
criminal  on  the  same  side  of  the  victim's  throat,  thus  leaving  but  two 
marks  on  one  side  and  a  number  of  finger-marks  upon  the  opposite 
side.     In  these  cases  the  superficial   injury  to  the  tissues,  more  or  less 
clearly   defined    bruise-marks,    is   found  in  a  limited    area  not   higher 
than  over  the  thyroid  cartilages,  and  the  weaker  pressure  of  the  third 
and   fourth   digits  makes   little   impression,   as   the  upper  part  of  the 
throat    receives   the   compression   of   these    less    powerful    constrictors. 
Or,  the  criminal  directly  anterior  to  the  victim — as,  for  instance,  when 
kneeling  on  the  chest  or  abdomen  and  throttling  at  the  same  time — the 
thumb-marks  are  upon  opposite  sides  of  the  wind]iii)e,  and  the  upper- 
most injuries  are  apt  to  be  high  up  along  the  throat.      Injuries  to  the 
back  of  the  neck  may  also  be  produced,  one  hand  being  a|i])lied  poste- 
riorly, the  other  anteriorly,  in  order  to  accomplish  compression  more  thor- 
oughly.    In  very  many  instances  the  murderer  has  but  one  hand  engaged 
about  the  tliroat,  and  one  level  receives  the  injuries  from  compression,  the 
struo-ffles  of  the  victim  demanding;  the  use  of  the  other  hand  for  various 
purposes.    Even  when  the  bruises  are  seen  all  along  the  throat,  however, 
only  one  hand  moved  from  time  to  time  may  have  been  engaged.     Usu- 
ally in  throttling  by  hand,  unless  the  victim  has  been  very  helpless  from 
childhood,  age,  disease,  or  from  being  bound,  other  marks  of  violence 
will  be  found,  as  it  is  extremely  difficult  for  tlie  criminal  to  accomplish 
the  act  of  strangulation  by  hand  on  account  of  the  strugo-les  and  op])o- 
sition  of  the  person  assaulted.     In  this  form  of  throttling  the  backward 


192  DEATH    FROM    ASPHYXIA, 

and  inward  pressure  of  the  compressing  hand  does  not  so  certainly  pro- 
duce obstruction  of  the  jugulars,  and  the  degree  of  congestion  of  the  face 
and  brain  is  here  usually  less  marked  than  in  other  forms  of  strangu- 
lation. 

Throttling  by  means  of  a  constricting  band  is  practised  in  a  great 
variety  of  ways  and  with  various  materials.  The  Turks  use  a  strong 
bowstring  in  judicial  executions,  twisting  it  about  the  neck  and  thus 
producing  a  deep  and  thorough  constriction  of  air-passages  and  blood- 
vessels in  a  comparatively  short  time.  The  steel  collar,  or  garrote,  used 
by  the  Spanish  produces  its  effects  in  the  same  way,  although  the  area 
of  compression  is  larger  here  than  where  a  small  cord  has  been  em- 
ployed. A  broader  band,  made  by  the  folding  of  a  piece  of  cloth,  has 
been  successfully  used  for  murderous  purposes  in  the  same  way  by  the 
thugs  of  East  India  and  other  criminals.  It  has  the  advantage  of 
leaving  little  postmortem  sign  of  injury  to  the  superficial  parts  of  the 
neck. 

Women  have  been  known  to  strangle  themselves  with  their  hair  ; 
straps,  ropes,  wrapping-cord,  neck-cloths,  suspenders,  and  a  host  of 
similar  substances  have  been  in  this  or  that  case  used  suicidally  or 
homicidally.  In  suicidal  strangling  by  this  method  the  ligature  is,  of 
course,  found  about  the  neck,  sometimes  fastened  by  a  hurried  knot  or 
partial  tie,  sometimes  merely  wra])]K'd  tiglitly  several  times  about  the 
neck.  In  homicidal  throttling  by  ligature  the  latter  is  not  so  uniformly 
found,  the  criminal  often  seeking  to  conceal  the  mode  of  death.  A  handle 
of  wood  is,  perhaps,  especially  in  suicidal  cases,  found  twisted  into  the 
ligature,  as  in  a  hand  tourniquet,  in  order  to  give  an  easy  purchase  in 
producing  the  constriction.  Pieces  of  stone,  wood,  or  other  solid  mate- 
rial may  be  found  in  the  constricting  band.  They  are  applied  directly 
over  the  air-passage  and  insure  more  thorough  compression  ;  or  knots 
are  sometimes  tied  in  the  ligature  and  applied  in  the  same  way  for  the 
same  purpose. 

Symptoms. — Occasionally,  probably  by  the  suddenness  and  force 
of  compression  upon  the  pneumogastric  nerves,  death  occurs  immediately 
in  throttling  by  cardiac  inhibition.  The  preexistence  of  cardiac  disease 
doubtless  favors  such  a  denouement.  Usually,  however,  a  number  of 
minutes  intervene  before  the  victim  dies,  and  a  number  of  symptoms 
generally  occur,  as  already  outlined.  Violent  struggles  are,  of  course, 
always  attempted  in  homicidal  throttling,  and  only  a  greatly  superior 
force  of  the  assailants  or  some  jirecaution,  as  binding  the  arms  and  limbs 
or  the  production  of  stupefaction,  can  prevent  the  evidences  of  these 
struggles. 

In  suicidal  throttling  the  patient,  while  the  ligature  is  being  ajiplied 
and  fastened,  is  quiet  for  a  few  seconds,  l)ut  quickly  violent  efforts  to 
breathe  ensue.  Unconsciousness,  preceded  by  great  fulness  in  the  head, 
lividity  of  the  face,  a  roaring  in  the  ears,  and  bulging  of  the  eyeballs, 
quickly  comes  on,  thus  preventing  the  self-relief  which  otherwise  would 
in  a  large  number  of  cases  be  applied  effectively.  During  these  few 
moments   it  is  said   the   mind   is  very  active.     The   same   phenomena 


DEATH    BY    THROTTLING.  193 

iiiujiK'stiouably  occur  in  homicidal  throttling.  After  a  few  violent 
respiratory  efforts,  as  unconsciousness  comes  on,  the  respirations  become 
progressively  weaker  and  more  and  more  irregular,  and  usually  stop  ' 
after  four  or  six  minutes.  A  few  irregular  etlbrts  to  gasp  may  be 
noticed,  however,  as  nnich  as  eight  or  ten  or  UKjre  minutes  after  the 
com])ression  has  been  applied.  The  heart  at  first  becomes  suddenly 
rapid  and  violent,  but  quickly  loses  its  force  and  gradually  subsides; 
the  heart-beats,  however,  may  persist  a  number  of  minutes  after  the  last 
respiratory  efforts.  In  a  very  few  minutes  after  constriction  of  the 
neck,  if  the  least  possil)le  amount  of  air  can  pass  tlie  constriction,  small 
rales  may  be  heard  in  the  trachea.  Gas  and  solid  matter  may  be  passed 
by  the  rectum  in  the  struggle  of  the  i)atient ;  urine  may  be  voided. 
The  genitals  are  apt  to  become  turgid,  and  sometimes  semen  is  dis- 
charged ;  usually,  however,  the  semen  is  discharged  only  into  the  ure- 
thra, and  later  than  during  the  struggles  of  the  victim,  often  probably  by 
the  rigor  of  the  walls  of  the  seminal  vesicles  just  after  death.  Hemor- 
rhages from  the  nose  and  ears  may  sometimes  result  from  the  venous 
fulness  of  their  vessels. 

Postmortem  Appearances. —  The  body  usually  becomes  rigid 
quickly,  although  this  partly  dei)ends  upon  the  amount  and  violence 
of  struiTirlinir  throudi  which  the  individual  has  passed.     The  face  is 

OO  O  O  111  • 

usually  swollen,  the  eyes  are  bulging  and  partly  open,  the  tongue  is 
swollen  and  protruding  or  between  the  teeth  ;  the  countenance  is  livid ; 
there  is  postmortem  lividity  in  dependent  parts  and  arms.  On  opening 
the  body  the  blood  is  found  dark  and  fluid,  present  especially  in  the  right 
side  of  the  heart  and  in  the  veins.  The  right  heart  is  distended,  the 
left  usually  contracted,  if  examined  early,  but  later  relaxed.  The  state 
of  the  lungs  seems  to  depend  in  a  measure  upon  the  amount  of  air  con- 
tained. Before  removing  these  organs,  and  in  fact  before  opening  the 
chest,  in  order  to  preserve  as  well  as  possible  the  pulmonary  condition, 
the  trachea  should  be  dissected  out  below  the  point  of  com]iression  and 
tied.  Sometimes  these  organs  are  found  comparatively  bloodless  except 
in  the  larger  vessels,  wdiich  contain  the  same  dark  fluid  blood  as  the 
veins  ;  and  often  a  condition  of  emphysema  about  the  borders  is  encoun- 
tered, probably  the  result  of  the  violent  efforts  at  ex])iration.  In  the 
bronchial  tubes  and  trachea  there  is  often  a  small  amount  of  bloody 
mucus  and  froth,  or  there  may  be  small  punctate  hemorrhages  in  the 
tissue.  In  other  cases,  especially  where  the  lungs  contain  less  air,  they 
are  found  highly  congested.  Small  interstitial  hemorrhages,  usually  of 
a  stellate  shape,  are  often  found  in  the  pericardium  and  ]ileune.  The 
abdominal  viscera  are  usually  deeply  congested,  and  there  are  fre- 
quentlv  seen  small  subserous  hemorrhages  or  hemorrhages  into  the 
mucous  membranes  of  the  stomach  and  intestine.  The  ])rain  and  cord 
may  be  much  congested,  and,  especially  when  the  jugulars  have  been 
much  compressed,  may  contain  areas  of  meningeal  or  jiarenchymatous 
hemorrhage.  Conjunctival  suffusions  often  exist.  Sometimes,  espe- 
cially where  one  or  other  or  both  the  jugulars  of  both  sides  have  escaped 
much  constriction,  as  may  happen  in  throttling  "by  the  hand,  or  where 

Vol.  L— 13 


194  DEATH    FROM    ASPHlTXIA. 

the  compression  is  soou  released,  the  ainouut  of  facial  swelling  and 
lividity  and  cerebral  congestion  is  apt  to  be  insignificant. 

The  position  of  the  tongue  depends  in  part  upon  what  level  of  the 
neck  receives  the  force  of  compression  and  how  that  compression  is 
directed.  As  stated  by  Maschka,  if  the  compression  is  applied  high  up 
above  the  hyoid  bone,  the  tongue  is  forced  into  the  back  part  of  tlie 
mouth.  If  the  pressure  is  below  the  hyoid  bone,  the  tongue,  however, 
will  protrude  between  the  jaws  unless  the  compression  has  a  decidedly 
downward  direction,  when  its  position  is  apt  to  be  normal.  Of  greatest 
interest  are  the  marks  of  violence  upon  the  throat.  These  marks  are 
those  resulting  from  the  bruising  and  capillary  laceration  caused  by 
violence.  When  the  strangling  has  been  performed  by  a  murderer's 
hand,  these  marks  show  as  dark-l)luish  or  brownish  blotches  following 
the  outline  of  compression  by  fingers  and  thumb.  They  occur  at  dif- 
ferent levels,  as  a  rule,  on  the  two  sides  of  the  throat,  that  of  the  thumb 
o;enerallv  beintj  a  little  hio-her  than  those  caused  bv  the  fingers.  On 
dissection  a  greater  or  less  amount  of  blood  and  tissue  laceration  is 
found  in  the  structures  immediately  underlying  tliese  areas.  When  the 
compression  has  been  effected  by  a  ligatin-c,  a  line  of  depression  corre- 
sponding ronghly  to  the  width  of  the  constricting  band  is  found,  but 
where  a  soft  broad  ligature  is  used,  as  a  cloth,  this  may  be  missing ; 
again,  if  the  ligature  is  removed  before  life  is  quite  extinct,  this 
depression  is  likely  to  be  but  slightly  marked.  This  line  is  usually 
marked  l)y  ecchymotic  patches,  which  are,  however,  less  likely  to  be 
present  if  there  has  been  no  violence  exerted  in  the  application  of  the 
compression ;  and  many  look  upon  the  presence  of  such  suggillations  as 
evidence  of  violence.  This  line  is  generally  disposed  horizontally  about 
the  neck,  in  contrast  with  the  diagonal  direction  of  the  similar  line  in 
case  of  death  by  hanging. 

If  there  has  been  very  deep  depression  and  excoriation  of  the  skin 
by  the  ligature,  this  line  becomes  peculiarly  dry,  hard,  and  parchment- 
like several  hours  after  death,  and  is  very  characteristic  in  such  cases. 
On  dissection  of  the  injured  parts  muscular  and  connective-tissue  lacera- 
tion, hemorrhagic  infiltrations,  density  of  the  soft  parts  from  compression 
are  usually  found,  and  it  is  not  infrequent  that  fractures  of  the  hyoid 
bone  or  of  the  thyroid  cartilages  or  similar  injuries  to  the  other  harder 
structures  in  the  vicinity  are  present.  It  is  of  note  that  this  area  of 
local  injury  is  likely  in  marked  cases  to  persist  for  a  very  long  time  in 
a  recoo:nizable  deo;ree ;  and  in  the  celebrated  Houet  case,  in  Paris, 
served  as  an  important  part  of  the  evidence  to  the  conviction  of  the 
murderess  eleven  years  after  the  death  and  burial  of  the  victim. 

In  the  determination  of  cases  supposed  to  have  perished  from 
strangulation  by  one  or  other  form  of  throttling  the  first  effort  is  to  be 
made  to  establish  the  actual  fiict  of  such  mode  of  death,  and  thereafter 
to  detect  whether  such  strangulation  has  been  homicidal,  suicidal,  or 
accidental.  The  absolute  determination  of  the  former  proposition  is  by 
no  means  a  simple  one,  since  the  signs  upon  the  body  may  all  be  more 
or  less  modified  by  circumstances. 


DEATH    KY    THROTTLING.  195 

The  coini)arative  value  of  these  sig:ns  is  variously  reg:ar(le(l  by  different 
writers,  and  the  combination  of  existing  signs  should  be  the  basis  of 
opinion  rather  than  the  degree  of  presentation  of  this  or  tliat  particular 
appearance.  Thus,  while  the  existence  of  marks  upon  the  neck  is  of 
unf|nesti(tnablc  value,  it  must  not  he  neglected  that  death  ])y  strangula- 
tion may  iiave  l)een  accomplished  w  ithoiit  their  production,  and  that,  on 
the  other  hand,  they  may  have  been  produced  accidently  by  the  patient's 
own  hand  or  l)y  the  impact  of  some  hard  substance  against  the  neck 
upon  which  tlie  patient  may  have  faik'n  in  a  tit  or  otherwise,  or  may 
have  been  produced  postmortem.  While,  when  considered  with  the 
other  features  of  the  case,  the  dark,  fluid  blood,  the  congested  condition 
of  tiie  lungs,  the  presence  of  emphysema  of  the  lungs  and  of  hemorrhages 
in  different  situations  are  of  much  importance  in  the  general  estimate,  it 
must  not  be  forgotten  that  these  are  possible  in  various  forms  of  asphyxia 
and  that  they  may  be  closely  simulated  by  natural  disease.  The  presence 
of  signs  of  violence  in  other  j^arts  of  the  l)ody  than  the  neck,  too,  is 
of  much  importance,  since  it  is  <piite  possilde  that  before  the  apjdication 
of  the  ligature  the  victim  was  rendered  insensible  by  a  blow  upon  the 
head.  ]\Iarks  of  violence  also  are  found  in  such  cases  about  the  chest 
or  abdomen,  fractures  of  ribs,  bruises  of  the  chest  and  abdomen,  or 
injuries  to  tiie  abdominal  viscera,  the  result  of  kneeling  upon  these 
parts  in  order  to  liasten  the  asphyxiation.  In  tiie  absence  of  other 
lesions  capable  of  accounting  for  death  naturally,  and  in  the  presence 
of  surrounding  circumstances  of  corroborative  nature,  the  absence  or 
incompleteness  of  this  or  that  appearance  usually  regarded  as  significant 
is  of  minor  importance  ;  and,  conversely,  the  utmost  caution  siiould  be 
observed  in  any  absolute  statement  if  there  exist  the  least  demonstrable 
possibility  of  death  from  natural  influences,  or  if  no  outside  evidence  is 
found  in  confirmation  of  the  suspicion  of  death  l)v  throttling. 

Where,  however,  there  is  both  external  and  bodily  evidence  of  death 
by  strangulation,  further  inquiry  as  to  the  exact  mode  is  necessarv, 
whether  bv  hanw-ino;  or  bv  one  of  the  modes  of  throttlintr.  The  mere 
discovery  of  a  body  suspended  does  not  affirm  that  death  occurred  by 
hanging,  although  with  the  general  ajipearances  corroborating,  such  a 
supposition  is  reasonably  tenable.  The  position  of  the  ligature  about  the 
neck  and  the  direction  of  the  line  of  depression  constitute  the  most 
important  elements  of  evidence  in  differentiation  of  these  modes  of 
destruction,  the  ligature  and  mark  of  the  same  having  a  horizontid 
direction  in  case  of  throttling,  while  in  ordinary  hanging  these  present 
an  oblique  disposition,  extending  from  point  of  lowest  contact  upward 
and  about  the  neck  to  the  ])oint  of  adjustment  of  the  susi)ended 
loop.  In  many  cases,  too,  the  greater  violence  done  to  the  tissues,  the 
parchment-like  appearance  of  the  skin  in  the  line  of  dej)ression,  the 
marked  ecchymoses  along  this  line,  the  rupture  of  tiie  cervical  muscles, 
particularly  the  sternocleidomastoid,  the  rupture  of  tiie  inner  coats  of 
the  carotid  arteries,  the  fracture  of  vertebrae  or  their  dislocation,  speak 
clearly  for  death  l)y  hanging.  Yet  it  should  be  remembered  that  in 
eases  of  suicide  by  so-called   "  partial   suspension,"  if  the  ligature  has 


196  DEATH    FROM    ASPHYXIA. 

been  sufficiently  soft  and  broad,  and  a  comparatively  small  part  of  the 
body-weight  actually  suspended,  or  the  constricting  band  from  adjust- 
ment and  position  of  the  victim  be  in  a  horizontal  direction,  nothing 
save  the  circumstances  surrounding  the  case  can  serve  to  diiferentiate. 
Moreover,  after  the  individual  has  been  killed  by  throttling,  perhaps 
with  little  or  no  sign  remaining  to  indicate  the  mode  of  destruction 
from  any  other  form  of  asphyxia,  the  IxkIv  may  be  placed  in  such  ])osi- 
tion  and  surroundings  as  to  indicate  quite  a  ditferent  mode  of  destruction. 
Thus,  as  cases  exist  on  record,  a  body  dead  by  throttling  may  have 
been  immediately  suspended,  marks  upon  the  neck  being  capable  of 
production  within  half  an  hour  to  an  hour  after  deatii  so  as  to  be 
identical  with  those  ordinarily  produced  by  hanging.  Under  such  cir- 
cumstances the  idea  of  suicide  may  be  with  difficulty  avoided ;  and  only 
the  greatest  care  in  recognition  of  evidence  in  the  surroundings  and  of 
marks  of  violence  incompatible  with  suicide  by  hanging  upon  the 
person  of  the  victim  can  serve  to  present  competent  testimony  of  death 
by  other  than  suicidal  means. 

In  endeavoring  to  determine  the  question  of  suicide  or  homicide  in 
those  dead  from  throttling  the  character  and  severity  as  well  as  the  posi- 
tion of  marks  of  violence  upon  the  neck  and  elsewhere  should  be  re- 
garded, and,  too,  the  presence  or  absence  of  a  ligature  about  the  neck,  as 
well  as  the  simplicity  or  complicated  manner  of  its  a])plication  and  fixa- 
tion. Finger-marks  alone  upon  the  throat  of  a  body,  M'ithout  the  sign 
of  the  use  of  a  ligature,  if  accomjianied  by  the  internal  evidence  of  death 
by  asphyxia  and  by  injuries  to  the  deeper  structures  of  the  throat,  may 
be  looked  upon  as  strong  evidence  of  murder,  since  it  is  not  probable 
that  sufficient  violence  to  the  neck  could  be  self-inflicted  to  produce  the 
deeper  lesions  about  the  throat.  Yet  even  where  the  condition  of  the 
blood  and  heart  and  other  viscera  indicates  asphyxiation,  mere  finger- 
marks upon  the  surface  unsupported  by  deeper  injuries  may  have 
been  produced  by  the  victim  himself,  either  consciously  or  uncon- 
sciously. 

When  throttling  has  been  due  to  a  ligature,  the  nicer  degrees  of 
adaptation  of  a  knot  or  inserted  hard  substance  to  the  trachea  or  larynx 
of  itself  speaks  rather  for  the  case  of  suicide,  the  haste  and  pertitrbation 
of  the  murderer  more  freqttently  preventing  careful  adjustment.  Sui- 
cides by  this  method  may  show  some  measure  of  failure  properly  to  fix 
the  ligature  on  account  of  oncoming  unconsciousness  or  loss  of  presence 
of  mind.  The  use  of  a  small  stick  or  similar  object  as  a  tourniquet 
windlass  after  comparatively  loose  application  of  the  ligature  has  fre- 
qttently been  encountered,  the  twist  being  prevented  from  becoming 
free  by  the  stick  locking  against  the  ground  or  person  of  the  suicide. 
In  homicidal  throttling  l)y  ligature  tmdue  force  is  likely  to  be  a])plied 
in  various  ways,  and  injuries  of  different  forms  inflicted  in  diflerent 
parts  of  the  body.  From  violence  of  application  of  the  ligature  or 
from  jerking  or  wrenching  the  neck  by  means  of  the  ligature,  the 
parchment-like  skin  in  the  line  of  depression,  ecchymoses  along  this 
line  and  the  more  serious  strtictural  changes  of  the  deeper  parts  are 


DEATH    BY    HANGING.  197 

likely  to  be  found,  and  hence  these  are  indicative  rather  of  murder  than 
of  suicide. 

There  is  usually  little  difficulty  in  the  determination  of  this  question, 
however;  and  in  cases  where  tiie  evidence  of  throttling  is  sufficiently 
clear  to  establish  this  mode  of  deatii,  rarely  arc  signs  wanting  to 
classify  it  as  homicidal  or  suicidal  eitiicr  u|)on  the  body  or  in  the 
surroundings  and  general  testimony.  A  much  more  difficult  task  is 
the  detection  of  those  cases  where  the  throttling  has  been  skilfully  done 
with  a  broad  soft  ligature  and  the  ligature  immediately  removed.  In 
some  instances  all  that  can  be  said  is  that  death  has  resulted  from 
asphyxiation  ;  and  apart  from  extrinsic  testimony,  no  positive  decision 
as  to  the  mode  of  its  production  can  be  giveu.  The  careful  exclusion 
of  every  appreciable  natural  cause  in  such  cases  is,  however,  of  consid- 
erable value,  and  if  associated  with  sufficiently  corroborative  evidence 
from  the  surroundings,  general  testimony  may  serve  reasonably  to 
estaijlish  nnuxlerous  guilt.  The  absence  of  superficial  marks  of  violence 
should  not  deter  the  examiner  from  careful  dissection  of  the  deeper 
structures  of  the  throat,  since  serious  lesions  of  these  parts  may  exist 
without  any  external  sign. 

Accidental  throttling  is  rare,  but  death  has  been  knovv^n  to  occur 
thus.  Excessively  tight  collars  or  neckbands,  the  entanglement  of 
neckties  in  moving  machinery,  the  slipping  of  some  band  sustaining  a 
weight  upon  the  back  from  forehead  or  shoulders  to  encircle  the  neck, 
the  foolish  application  of  constrictions  about  the  neck  for  purposes  of 
show,  the  compression  exerted  by  the  edge  of  a  bedljoard  ujion  the  neck 
while  the  head  liangs  over  the  side,  and  similar  modes  of  production 
have  been  capable  of  terminating  life  in  occasional  instances. 

Among  the  natural  causes  of  death  liable  to  misinterpretation  and 
confusion  with  the  foregoing,  apoplexies  are  perhaps  the  most  impor- 
tant, inasmuch  as  several  such  cases  have  led  to  legal  action  on  the 
supposition  of  strangulation.  The  fact  that  the  intense  cerebral  con- 
gestion in  strangulation  may  give  rise  to  apoplectic  effusions  in  the 
brain  makes  the  difficulty  of  diagnosis  all  the  greater  ;  yet  the  general 
rule  that  such  apoplexies  are  more  liable  to  occur  the  severer  the  force 
of  compression  about  the  neck  will,  in  most  instances  where  the  external 
testimony  permits,  relieve  the  suspicion  if  marks  of  such  violence  be 
absent  from  the  dead  body.  The  condition  of  the  l)Iood  and  internal 
viscera  will,  moreover,  serve  in  most  cases  to  render  the  decision  more 
easy,  since  in  ordinary  apoplexies  the  blood  is  not  fluid  and  there  are 
often  lesions  of  the  heart  and  vascular  changes  of  greater  or  less  im- 
portance. Death  in  profound  alcoholic  or  o]iium  narcosis  may  likewise 
mislead,  and  should  carefully  be  excluded. 

2.  Death  by  Hanging". — Death  by  hanging  is  a  form  of  strangu- 
lation where  the  more  or  less  completely  suspended  body  of  the  victim 
by  its  weight  exerts  the  force  necessar}'  to  compress  the  structures  of 
the  neck  against  the  fixed  ligature  encircling  it,  and  thus  produce 
respiratory  obstruction.  As  a  matter  of  fact,  death  by  asphyxia  does 
not   ahvays    occur   in   hanging.      Cerebral    congestions    or   apoplexies, 


198  DEATH    FROM    ASPHYXIA. 

injuries  to  the  cerebral  cord  or  to  the  pneiimo_o^astric  nerves  are  some- 
times produced  in  the  process  and  may  cause  death.  In  the  majority 
of  cases,  however,  asphyxiation  is  the  mode  of  oncome  of  death. 
Hanging  is  in  most  of  the  states  of  this  country  and  in  manv  other 
lands  the  judicial  method  of  terminating  life.  It  is  a  frequent  method 
of  self-destruction,  is  often  employed  homicidally,  especially  in  "  lynch- 
ing," and  occasionally  is  accidental. 

In  judicial  hanging  the  doomed  individual  is  caused  to  stand  upon 
a  trap-door  in  the  floor  of  an  elevated  stage  or  scaffold  ;  the  arms  and 
limbs  are  pinioned  ;  sight  is  prevented  by  a  cap  over  the  face  and  the 
noose  or  loop  of  a  rope  is  placed  about  the  neck.  Tiie  rojie  selected 
should  have  been  tested  to  prove  its  strength,  and  for  advantage  should 
be  rather  pliable  and  elastic.  Its  upper  end  is  firmly  attached  at  a 
variable  height  above  the  head  of  the  criminal  about  to  be  executed, 
and  sufficient  length  allowed  to  permit  a  fall  of  the  body  of  from  1  to 
10  feet,  usually  5  or  6  feet.  The  length  of  the  "drop  "is  usually 
arranged  in  inverse  proj^ortion  to  the  weight  of  the  victim's  body.  The 
adjustment  of  the  loop  has  been  the  subject  of  considerable  discussion. 
It  is  usually  drawn  comfortably  tight  about  the  upper  part  of  the  neck, 
and  so  arranged  that  the  knot  is  placed  just  below  and  behind  one  ear. 
Sometimes,  however,  the  knot  is  adjusted  to  the  back  of  the  neck  ; 
and  where  it  is  desired  to  "  break  the  neck "  of  the  criminal,  it  is 
arranged  anteriorly  beneath  the  chin.  These  ])reparations  complete, 
the  trap-door  upon  which  the  culprit  stands  is  allowed  to  fall;  and  the 
body  of  the  victim  drops  to  the  length  of  the  rope. 

If  the  knot  has  been  properly  arranged,  the  drop  of  sufficient  dis- 
tance, and  the  suspended  body  of  a  sufficient  weight,  death  may  occur 
at  once  from  injury  to  the  spinal  cord  or  medulla  by  dislocation  of  the 
vertebrae  or  fracture  of  the  odontoid  process  of  the  axis.  No  exact 
estimate  can  be  given  of  the  frequency  of  such  occurrence,  since,  for  its 
production  with  any  uniformity,  it  requires  that  special  provisions  shall 
have  been  taken.  In  order  to  accomplish  this  end  the  knot  should  be 
large  and  adjusted  close  to  the  neck  on  the  side  or  beneath  the  chin, 
and  the  drop  should  be  as  long  as  possible,  10  feet  being  recommended 
by  Houghton.  Immediate  death  occasionally  may  ensue  from  the  sud- 
den sliarp  pressure  upon  the  vagus  nerves,  because  of  the  complete  and 
rapid  inhibition  of  the  heart. 

Congestive  apo]>lexies  or  occasionally  true  effiisive  apoplexies  may 
0])erate  to  destroy  life  more  rapidly  than  is  usually  the  case  in  asphyxia- 
tion alone.  In  the  majority  of  cases,  however,  death  occurs  from 
asphyxia  or  from  asphyxia  associated  with  one  or  more  of  these  other 
possibilities,  and  requires  from  eiglit  to  twenty  or  more  minutes  after 
the  victim  has  fallen.  When  death  is  immediate,  the  body,  except  for 
a  few  slight  muscular  quivers,  hangs  motionless,  the  head  fallen  over  to 
the  side  opposite  the  knot  and  the  neck  looking  unusually  long.  In 
the  ordinary  cases,  where  asphyxiation  plays  the  major  or  only  part  in 
destroying  life,  there  ensue  the  usual  stages,  as  described  in  strangula- 
tion by  any  form  of  ligature,  except  that  from  the  violence  of  the  fail 


DEATH     i;V     IIANGTXG.  199 

the  first  stage  is  usually  not  of  active  and  exalted  eonscionsness,  l)ut  of 
iinniediate  uneousciousuess.  Occasionally,  however,  it  is  [)robable,  from 
the  ex})erience  of  a  few  of  those  rescued  before  death  was  complete,  that 
the  sam(>  mental  activity,  the  same  crowding  of  ])ast  events  into  the 
memory  for  a  second  or  two,  does  take  })lace.  As  soon  as  the  drop  has 
fallen  the  body,  for  a  few  seconds  to  a  minute  or  more,  hangs  limj)  and 
quiet  ;  then  convulsive  movements  take  place,  persisting  for  two  or 
three  minutes.  These  are  :  drawing  uj)  of  the  arms  and  limbs,  clench- 
iuLi-  of  the  hands,  heavinir  of  the  chest,  and  other  contortions  made 
in  the  efforts  to  respire.  These  soon  disappear,  except  that  possibly 
some  minutes  later  slight  respiratory  efforts  may  be  noted  or  muscular 
quiverings  be  manifested  here  and  there.  For  the  first  few  seconds  the 
face  is  pale ;  then,  as  the  convulsive  movements  occur,  it  becomes 
more  and  more  deeply  livid,  and  little  blotches  may  occur  beneath  the 
skin.  The  face  becomes  swollen  ;  the  eyes  bulge ;  the  month  hangs 
open  ;  the  tongue  shows  between  the  teeth  ;  free  salivation  is  likely  to 
occur,  and  the  saliva  drops  from  the  corners  of  the  mouth.  Slight 
bleeding  from  the  tongue,  where  it  has  been  bitten  by  the  early  con- 
vulsive movements  of  the  ja\v,  or  from  the  nose,  on  account  of  venous 
congestion,  may  appear  about  the  face.  The  external  genitals  are  likely 
to  become  turgid  ;  urine  and  feces  or  gas  may  be  voided  ;  occasionally 
there  are  discharges  of  genital  fluid,  although  this  is  not  imiform,  and 
probably  is  not  accompanied  by  erotic  feelings,  as  has  been  claimed. 
The  seminal  discharge  is  more  frequently  only  partial  and  into  the 
urethra,  occurring  just  after  death  fr(»m  the  (piickly  appearing  rigid- 
ity and  contraction  of  the  walls  of  the  seminal  vesicles.  The  pulse  is 
at  first  quick,  hard,  and  full,  but  rapidly  loses  in  force,  fulness,  even- 
ness, and  disappears  a  few  minutes  after  the  closing  of  the  convulsive 
stage.  The  heart-beats  persist  for  a  longer  time,  however,  becoming 
more  and  more  feeble  and  irregular,  and  finally,  after  ten  or  twenty 
minutes  from  the  beginning,  they  cease,  and  death  is  complete. 

The  first  stage  is  one  of  quietude,  consciousness  being  possible  ;  it 
lasts,  as  stated,  for  from  but  a  few  seconds  to  about  one  or  one  and  a 
half  minutes.  It  is  succeeded  by  the  stage  of  resjiiratorv  eftort  and 
convulsive  movements,  lasting  from  two  to  foiu'  or  five  minutes. 
Unconsciousness  is  invariably  present  after  a  few  seconds  of  this  ])criod. 
The  third  stage  is  one  of  almost  absolute  quiescence,  marked  by  but 
few  and  feeble  efforts  at  respiration  ;  the  heart  continues  to  beat, 
becoming  progressively  weaker  and  weaker.  \\'ith  the  cessation  of 
circulation  this  third  stage  is  complete  and  life  is  extinct.  The  third 
stage  is  usually  longer  than  both  the  others,  often  lasting  twelve  or 
fifteen  minutes. 

Iloinmdal  ham/inf/,  as  in  lynching,  is  often  very  similarly  performed, 
the  drop  being  accomj)lished  by  the  sudden  removal  of  some  elevated 
support  upon  which  the  victini  has  been  standing.  Thus  after  the 
adjustment  of  the  noose  and  the  fixation  of  the  rope  to  a  limb  of  a 
tree  or  some  similar  object  above  the  level  of  the  victim's  head,  the 
chair  or  box  on  which  the  unhappy  wTetch  has  been  standing  may  be 


200  DEATH    FROM    ASPHYXIA. 

kicked  or  jerked  from  under  his  feet,  or  the  cart  upon  which  he  has 
been  supported  is  dragged  away.  In  all  such  cases,  as  a  rule,  the 
length  of  fall  is  small  compared  with  that  in  judicial  hanging,  the  chance 
of  breaking  the  neck  is  comparatively  slight,  and  death  generally  occurs 
by  asphyxia.  More  often  in  lynching  the  victim  is  drawn  up  by  the 
neck  from  the  ground  and  held  suspended  until  death  has  taken  place. 
Breaking  the  neck  by  this  method  is  almost  unknown,  and  the  absence 
of  the  violence  of  the  fall  results  in  slighter  local  damage  to  the  cervical 
structures  generally. 

Suicidal  hangim/  may  resemble  judicial  hanging,  but  there  is  rarely 
much  drop.  The  individual,  after  adjusting  the  rope  and  noose,  may 
jump  from  a  table,  a  chair,  or  other  object  upon  which  he  was  stand- 
ing, or,  suspended  by  a  short  rope,  may  kick  such  an  object  from  under 
his  feet.  Frequently,  in  case  of  suicide,  susj)ension  is  only  partial,  the 
body  being  found  alter  death  with  the  feet  touching  the  floor  or  ground, 
or  in  a  kneeling  posture,  sitting,  or  even  lying  prone,  with  only  the 
head  and  neck  in  suspension.  The  point  of  fixation  of  the  ligature, 
moreover,  may  be  entirely  insufficient  to  support  the  weight  of  the 
body,  a  clothes-hook  or  nail  partly  driven  into  some  support  being 
perhaps  employed.  Very  slight  ligatures  also  may  be  used  in  these 
cases  of  partial  or  incomplete  hanging,  as  thin  twine  or  cord,  pieces  of 
clothing,  neckties,  suspenders,  stockings,  strings  of  shirts,  or  similar 
substances.  Bodies  may  occasionally  be  found  half  supported  by  the 
ligature,  half  leaning  against  a  wall,  with  perhaps  only  a  thin  bit  of 
twine  encircling  the  neck  and  insecurely  attached  above  the  looj). 
Usually  in  these  cases  the  hands  are  quite  free,  and  only  an  indomitable 
will  or  the  rapid  loss  of  consciousness  and  physical  control  could  ]ire- 
vent  frequent  withdrawals  from  this  practice  of  suicide  after  it  had 
been  begun.  The  latter  is  probably  the  better  exjilanation  of  the 
almost  universal  success.  Sometimes,  however,  fearful  of  involuntary 
self-interference,  the  victim  has  bound  his  hands,  using  his  teeth  to  aid 
in  fastening  the  knot ;  such  a  precaution  is,  however,  quite  rare,  and  is 
unlikely  to  add  much  to  the  perplexities  of  the  case,  as  the  position  of 
the  pinioned  hands  in  front,  rather  than  l)ehind,  the  body,  and  the 
general  appearances  of  the  knot  should  indicate  its  application  by  the 
victim  rather  than  by  another. 

As  a  general  rule,  death  from  suicidal  hanging  is  one  of  pure 
asphyxiation,  the  comparatively  slight  violence  of  these  cases  rarely 
giving  rise  to  the  severe  injuries  of  the  cord  and  spinal  column  or 
other  important  cervical  structures  liable  in  cases  of  judicial  hanging. 
Syncopal  attacks  with  fatal  termination  from  compression  of  the  vagus 
and  disturbance  of  the  circulation  by  the  ligature  do,  however,  fre- 
quently occur. 

Accidental  hanging  is  very  rare.  Children  playing  in  swings  or  with 
ropes  may  occasionally  become  entangled  in  such  a  May  that  strangula- 
tion occurs.  One  now  and  again  meets  instances  of  where  a  child  slips 
from  a  fence,  and,  in  falling,  has  its  neck  caught  between  the  upper 
ends  of  the  palings,  with  the  result  of  death  by  suspension  if  not  at 


DEATH    BV    HANGING.  201 

once  relieved.  In  play  and  in  pnblic  show  persons  have  been  known 
to  be  suspended  })artially  or  c()mi)letcly  ;  and  accidents  liave  now  and 
then  taken  place  under  sucli  conditions.  The  circumstances  lure  are 
usually  so  com])lete  that  only  the  most  formal  inquiry  arises  and  there  is 
rarely  opportunity  for  implication  of  the  living  in  any  principal  part. 

In  all  these  varieties  of  suspension  the  phenomena  occurring  in  the 
course  of  the  process  are  identical  witli  those  of  judicial  hanging;  or, 
in  the  case  of  jxutial  sus})cnsion  and  suspension  without  a  droj),  with 
those  of  throttling  by  lig-aturc.  ^^'ilcn  there  is  a  decided  fall  of  the 
victim,  with  the  sudden  jerk  ui'  the  rope  aijout  the  neck  consciousness 
may  be  destroyed  at  once,  and  probably  is  destroyed  in  a  large  nimiber 
of  cases.  The  body  is  motionless,  as  if  stunned  ;  and  it  is  the  testi- 
mony of  a  number  who  have  been  rescued  immediately  that  they  pos- 
sessed absolutely  no  recollection  of  the  hanging.  If  consciousness  is 
not  at  once  destroyed,  as  is  usual  when  there  is  no  fall,  a  moment  or 
two  of  quietude  intervene — the  natural  period  during  A\hich  the  breath 
may  be  held.  The  head  feels  full  and  almost  bursting ;  the  ears  ring 
and  roar;  there  is  a  feeling  of  Ixwlily  liglitness;  the  activity  of  the 
mind  is  greatly  increased,  and  the  whole  life  seems  to  pass  in  review 
in  the  second  or  two  of  consciousness.  A  feeling  of  necessity  to 
breathe  becomes  more  and  more  imperative,  and  desperate  efforts  are 
made,  but  without  success.  Unconsciousness  now  comes  on  quickly. 
The  first  stage  of  (piiet  passes  abruptly  into  that  of  convulsive,  irre- 
sponsible, involuntary  eff'orts  at  respiration,  lasting,  as  indicated,  for 
several  minutes,  and  identical  in  all  its  details  to  the  convulsive  stage 
of  judicial  hanging.  The  last  stage,  also,  characterized  by  the  per- 
sistence of  the  heart's  action  alone,  is  the  same  as  the  final  stage  of 
legal  executions. 

Many  of  the  phenomena  encountered  in  the  process  of  hanging  are 
subject  to  variation  depending  upon  circimistances  of  compression. 
Thus,  while  typically  the  face  becomes  cyanosed  and  swollen  from 
interference  with  the  venous  circulation  through  the  jugulars,  a  con- 
siderable proportion  of  individuals  present  a  pallid  countenance.  This 
is  especially  likely  to  be  the  case  when  death  occurs  quickly  from 
cardiac  syncope,  from  cfnnpression  of  the  vagi,  or  from  the  added 
influence  of  coexistent  cardiac  disease.  The  rapid  failure  of  circulation 
in  such  instances  gives  little  opportimity  for  the  accumulation  of  any 
marked  excess  of  blood  in  the  head  and  face.  So,  also,  ^vhen  the 
adjustment  of  the  loop  and  attachment  of  the  ligature  leaves  one  side 
of  the  neck  free  from  compression,  the  imimpeded  venous  channels  of 
such  an  area  carry  off"  the  blood  as  rapidly  as  it  can  be  brought  to 
the  head  through  the  partially  constricted  carotids.  In  judging  of 
the  influence  of  compression  on  the  vessels  of  the  neck,  most  text- 
books lay  too  much  stress  upon  the  production  of  an  anemia  of  the 
head  and  face  by  compression  of  the  common  carotid  arteries.  Both 
from  their  more  exposed  position  and  their  less  resistant  "vvalls,  the 
jugular  veins,  superficial  and  deep,  must  be  more  readily  and  more 
completely   obstructed    by    the   compression    of   a   ligature   about  the 


202  DEATH    FROM    ASPHYXIA. 

neck,  and  when  the  compression  is  sufficiently  serious  to  narrow  the 
arterial  flow,  the  venous  return  must  be  more  impeded.  It  is,  there- 
fore, natural  tliat  in  all  cases  where  there  is  deep  compression  of  the 
neck,  if  the  circulation  does  not  at  once  and  completely  cease,  there 
should  accumulate  through  the  vertebral  arteries  and  smaller  deep  col- 
lateral circulation  a  considerable  excess  of  blood  in  the  venous  and 
capillary  vessels  above  the  ligature.  Thus  a  pallid  countenance  can 
exist  only  where  this  venous  circulation  is,  at  least  in  part,  free,  or  where 
there  is  absolutely  no  further  access  of  blood  by  the  deep  and  unob- 
structed arteries  of  the  neck,  as  may  be  expected,  for  instance,  when 
death  has  occurred  from  syncope.  JNIoreover,  the  protrusion  of  the  eye- 
balls and  conjunctival  suffusions  which  frequently  occur  are  often  absent, 
dependent  largely  on  the  same  cause.  The  swelling  of  the  tongue, 
noticed  especially  about  the  base,  is  subject  to  similar  variations  for  the 
same  reasons. 

The  rapid  onset  of  imconsciousness  is  frequently  ascribed  to  a  cei'e- 
bral  anemia  from  compression  of  the  carotids,  but  it  is  rather  to  be 
referred  to  cerebral  congestion  of  a  passive  form  and  to  the  carboniza- 
tion of  the  unaerated  blood  passing  to  it  through  these  incompletely 
compressed  arteries  and  the  deeper  and  uninfluenced  vertebrals.  The 
mere  fact,  especially  in  those  cases  presenting  pallid  countenances,  that 
autopsy  often  fails  to  show  cerebral  congestion  of  any  marked  degree  is 
of  little  significance,  since  the  fluid  l)lood  readily  passes  downward  as 
soon  as  the  constriction  is  released  if  the  position  is  favorable.  Marked 
capillarv  congestions  about  the  lower  part  of  the  head  and  face  and  in 
the  neck  above  the  ligature  are  likely  to  ])ersist  without  difliision. 

The  position  of  the  tongue  is  less  frequently  recorded  as  varying. 
Usually  it  is  found  protruding  or  between  the  teeth,  but  sometimes 
it  seems  rather  retracted.  This  probably  depends  largely  upon  the 
position  of  the  ligature  and  its  line  of  traction.  When  the  ligature  is 
above  or  on  the  same  level  as  the  hyoid  l)one  and  the  knot  is  well 
adjusted  posteriorly,  so  that  the  force  is  directed  l)ackward,  the  root  of 
the  tongue  is  dragged  backward  in  the  pharyngeal  space,  and  probably 
aids  in  respiratory  obstruction.  If  the  knot  is  placed  more  anteriorly, 
this  line  of  traction  does  not  exist,  and  the  tongue  is  likely  to  remain 
in  a  relatively  normal  position  unless  forced  outward  by  respiratory 
efforts.  When  the  ligature  acts  ]x4ow  the  level  of  the  hyoid  bone,  its 
upward  traction  tends  to  force  before  it  the  structures  about  the  base  of 
the  tongue  and  cause  it  to  protrude  to  a  greater  or  less  degree. 

As  a  rule,  the  fuce  is  more  or  less  contorted  during  hanging,  and 
may  retain  this  ajipearance  after  death.  Very  often  it  is  quite  placid, 
an  ajipearanee  likely  to  coincide  with  pallor  of  the  countenance, 
althougii  not  invariably.  The  contortions  are  probably  the  exjires- 
sion  of  the  respiratory  struggles,  and  mark  those  cases  in  which 
asphyxiation  is  the  particular  mode  of  death  ;  while  if  death  follows 
the  breaking  of  the  neck  in  the  drop  or  occurs  in  a  syncopal  attack,  the 
countenance  is  naturally  unmoved.  It  is  difficult  to  explain  why  in 
some  the  hands  should  clench  with  intense  force  and  in  others  remain 


DEATH    IJY    HANGING.  203 

with  the  fingers  extended,  Uiit  such  is  the  case.  As  a  rule,  the  clenched 
hands  are  found  in  persons  dying  or  dead  from  complete  suspension  ; 
while  it  is  more  or  less  connnon  to  meet  the  hands  tpiite  open  in  inconi- 
])lete  suspension.  Tiie  turgescence  of  the  external  genitals,  the  dis- 
charge of  genital  fluid,  of  urine,  of  feces,  or  of  gas  are  symptoms  «)m- 
monly  alluded  to,  but  are  by  no  means  constant  phenomena,  and  are 
not  peculiar  to  death  by  strangulation.  The  lividity  and  swelling  of 
the  limbs  and  lower  part  of  the  trunk  suggest  that  the  i)artial  genital 
erections  met  in  these  cases  may  be  a  part  of  the  general  hyperemia 
from   y;ravitation. 

It  is  impossible  to  state  definitely  any  period  of  time  necessary 
to  destroy  life  by  hanging.  Life  may  cease  from  the  beginning  of  the 
process  or  may  persist  up  to  lialf  an  hour.  By  using  a  fixed  knot  and 
loose  loop,  and  adjusting  the  latter  anterior  to  the  ramus  of  the  jaw  and 
posteriorly  high  up  along  the  occipital  region,  individuals,  exhibitors 
mainly,  have  endured  complete  susi)ension  for  a  much  longer  time  ; 
several  accidents  have  taken  place  among  such  foolish  exhibitors  by 
the  slip])ing  of  the  knot,  thus  drawing  the  rope  l)ack  over  the  resjiira- 
tory  passages  and  causing  asphyxia.  Resuscitation  is  improbable  after 
the  termination  of  the  second  or  convulsive  stage,  and  even  in  this  stage 
the  chances  for  recovery  are  always  questionable.  Yet  so  long  as  the 
heart  continues  its  action  it  is  wise  to  use  every  endeavor  to  recover, 
since  patients  have  revived  after  some  minutes'  cessation  of  respiratory 
movement  and  several  hours  after  the  beginning  of  artificial  respira- 
tion. 

Postmortem  Appearances. — In  inspecting  the  body  of  one  dead 
by  hanging  care  should  be  taken  to  note  precisely  every  circumstance 
and  feature  possible  before  the  corpse  has  been  disturl)ed.  Evidences 
of  a  struggle,  the  manner  of  attachment  of  the  ligature,  marks  of  any 
kind  upon  the  ligature  or  surroundings,  the  mode  of  adjustment  of  the 
loo}),  the  prol)al)le  length  of  the  dro[),  etc.,  should  all  receive  attention. 
The  condition  of  the  face,  eyes,  mouth,  tongue,  hands,  limbs,  genitals, 
and  the  clothing  should  all  be  inspected  and  recorded.  Thereafter,  the 
body  having  been  lowered,  inspection  should  be  made  of  the  condition 
of  the  neck  and  fi)r  marks  of  violence  elsewhere  uj)on  the  exterior  of 
the  bodv. 

Many  diiferences  may  be  found  in  the  character  of  the  marks  of  the 
ligature.  Usually  there  is  a  single  line  of  depression,  })assing  obliquely 
about  the  neck,  most  marked  on  the  side  opposite  the  knot,  and  entirely 
absent  close  to  the  position  of  the  knot.  AVhen  the  position  of  the 
victim  has  been  such  that  the  force  of  sus|)ension  does  not  act  along  the 
line  of  the  axis  of  the  body,  as  is  often  the  case  in  incomplete  suspen- 
sion, instead  of  an  oblique  line  of  depression  tiie  mark  about  the  neck 
may  l)e  horizontal,  as  in  throttling  by  a  ligature.  However,  unless  a 
slip-knot  has  been  employed,  the  absence  of  the  mark  on  the  side  of 
the  neck  corresponding  to  the  knot  of  the  ligature  constitutes  an  impor- 
tant means  of  differentiation.  In  general,  the  looser  the  adjustment  of 
the  loop,  the  more  oblique  the  line  of  depression.      This  line  is  deeper, 


204  DEATH    FROM    ASPHYXIA. 

as  a  rule,  along  the  sides  of  the  neck,  the  opposition  of  the  larynx  and 
similar  structures  often  preventing  it  cutting  in  so  deeply  anteriorly. 
It  is  usually  less  marked  in  fat  persons  than  in  those  that  are  moder- 
ately spare.  The  weight  of  the  body  and  the  length  of  time  of  suspen- 
sion, as  well  as  the  size  and  nature  of  the  ligature,  are  important  factors 
in  determining  the  depth  of  the  depression.  If  the  loop  has  been  a 
double  one,  the  mark  is  also  double,  one  portion  having  a  horizontal 
and  the  other  an  oblique  direction  if  the  inner  part  of  the  noose  be  free 
to  slip.  Both  lines  will  be  oblique,  however,  if  both  strands  are  attached 
at  the  knot.  In  the  former  case  the  horizontal  mark  will  be  found  to 
extend  completely,  around  the  neck,  as  in  case  of  throttling  by  ligature. 
As  may  be  expected,  the  narrower  the  cord,  the  deeper  the  furrow  of 
depression.  As  a  rule,  this  furrow  is  pale  at  the  bottom,  and  the  mar- 
gins are  swollen  and  discolored. 

When  considerable  force  has  been  expended,  as  in  hanging  with  a 
fall,  suggillations  along  the  bottom  of  the  groove  are  often  found ;  but 
these  are  not  present,  for  the  entire  number  of  deaths  by  hanging,  in  as 
great  proportion  as  in  death  by  throttling.  Instead  of  pallor  along  the 
bottom  of  the  depressed  line,  if  the  suspension  has  been  brief  and  little 
excess  of  force  employed,  the  surface  may  look  normal  or  slightly  red 
in  color.  If  there  has  been  much  excoriation  by  the  ligature  and  the 
suspension  has  lasted  for  several  hours,  the  skin  in  the  bottom  of  the 
groove  may  have  a  yellowish-brown  tint  and  a  hard,  dry  appearance — 
the  so-called  "  parchment-skin."  Even  if  not  noted  upon  releasing  the 
body  from  suspension,  this  last  is  likely  to  develop  within  a  few  hours 
after  exposure  of  the  groove  to  the  air.  The  cyanotic  appearance  of 
the  upper  margin  of  the  groove  is  almost  invarial)le,  usually  appearing 
even  if  the  body  has  been  suspended  shortly  after  death  from  some 
other  cause.  The  cyanosis  of  the  lower  margin  is  usually  less  marked, 
and  may  be  absent.  Its  presence  is  a  fair  indication  that  hanging  was 
performed  antemortem.  Ecchymoses  along  the  margin  of  the  furrow 
are  more  conmion  above  the  line  of  the  ligature  than  below,  but,  except 
in  cases  of  hanging  with  drop,  are  less  frequent  than  in  throttling.  It 
is  to  be  remembered  that  the  appearance  of  this  line  of  depression  is  a 
relative  one,  and  that,  in  its  appreciation,  the  length  of  fall  and  conse- 
quent violence,  the  weight  of  the  suspended  body,  the  duration  of  sus- 
pension, and  the  width  and  nature  of  the  ligature  must  all  be  considered. 
Many  cases,  especially  of  suicidal  hanging,  fail  to  exhibit  it  at  all ;  and, 
on  the  other  hand,  it  may  in  a  measure  be  produced  by  suspending  the 
body  within  one  or  two  hours  after  death. 

When  the  body  has  been  almost  or  completely  suspended,  the  neck 
is  distinctly  elongated  and  plial)le.  This  is  not  necessarily  due  to  any 
vertebral  fracture,  but  may  result  from  the  stretching  of  the  interverte- 
bral tissues. 

Subject  to  variation,  as  already  considered,  the  other  external  ap])ear- 
ances  are  likely  to  be  found  as  follows  :  the  face  is  swollen,  cyanosed, 
and  blotched  ;  the  eyes  are  prominent  and  sometimes  the  seat  of  sub- 
conjunctival hemorrhage ;  the  tongue  is  swollen  and  partially  protrud- 


85  S 

»  — 

o  cr 

a  3 


'j>    w  ZL        t--  r: 


G- 

C 

Cj  -3 

s 

c 

S- 

1. 

S 

^ 

^ 

O 

d 

"^ 

l-J 

:? 

S' 

o* 

05 

B- 

o 

2 

p 

o 

ffl 

B 

?5 

3 

o 

en 

IT* 

3 

a- 

e- 

■n 

C 

ffl 

crt- 

03      *^ 


cr  CD 


u 


r  H 


"O 


o 


g    g 


x      -      C6 


5-  I  g-  .    s-  c 


O     3 
P-  - 


B  tf 

~    a 


o 


'«    -g     3 


3-    »■• 


D} 


2-.^  3   3 

JQ    ^     C^    fs 


o 

a 
>-i 

rt 

c 
c" 

01 

■1 

B 

ri- 
ft 


3     ^ 


3- 


5    ®    ►< 
2        a 

O    ai   . 


j-   - 

a 
a 


01    2. 


<^  ^  (Th  _^ 

C  <^  o  '~^ 

O  3^  1-^,  jj- 

„  3  a-  3 

^  ^  y-  " 

S"  i»r  ^.  p- 

S  ^  ^  <^ 

—  f^  o  ft> 

^  f^  =  -K 


eh 


T    Q 


l-K        P^ 


oi     Pj  "3 


3      Eo' 


3 


-     B     3 

^  03 

5-  3 


►^  p- 


a 

3- 
P 

O 

o 


Q 

C 

P 

3 


^ 

C 

p 

a- 

3 

» 

P 

o 

1 
5 

3 

1 

P 

_-. 

3 

—  ?r 

3     O 
Pj 


5  P  •" 

Pi  01     m 
^. '^     C 

3  6     = 

^  i     '^- 

C-  1^    c^ 

g.  o;    £. 

f5  St.  J"' 


£     3 


3 
re 

P-     g       01 


01  ►—   ^ 


?l  « 

3  ►-) 

a>  "( 

Ol  o 

a;  01 

o  2 


3^ 


5    n 


(.k-        ^        rf 


01 


77*    ^ 


o    —  ^  5 


n    ^  -    2. 

^^  E.  P    '^ 
•T*    rr     -#i     I— ♦- 


P  — 

p.  r^ 

s  ■-< 

P  <B 

P-  3 


•J.    S     -^     P-    - 


-T-  -^    5    5    -. 


re 

3 


P     o 

re    ^ 
c    =» 


p 
n 
re 

p 

3 


~i     »     P 

~      01      3 

P      P' 


p      -'      p. 


c    ~- 


■3     r    ^'     2; 


~    2    "" 


re 
re 

?r 

o 
re 

re 
B 


re 


X       C"     Ol 

re    p    ci- 

_  «    -■ 

X    ^  5 
ft        ji 

O    Vi     o 


re  3 

3  3_ 

P  3 

p  re    3 


01 

so' 


g  5 

re  re 

d  P- 

P-  m 


re 

o 


re 
re 


re 
re 

re 


?  S^  S  5' 

re  —  r»     Oi 

^  B  3-    C 

g"  s-  ^  S' 

®  3  .5 


5"  ^ 

re    01 

re    :i 


<^  3    re 

=  s  -< 

cr  5°    ft 


re  pj 


-»    o 

§  e! 

p.   3 

re  p^ 

-i  o 

re  Hfc, 

P  ? 

fiB 

B    o 

p.    3 

2    re 


o    -_, 


S'  B"       B 


c-r      ti,  M 


3 

r+- 

S" 

r+ 

re 

re 

3 

r+- 

p 

o 

P 

^ 

01. 

r*- 

ft! 

O 

Jq' 

(Tt- 

3 

3- 

o 

E^   1 


^^  re    03    re    P- 


re 
< 
re 
p 

p 


B  3-  ^ 

p  re    oi 

re  5.  re 

P-  CB      „ 

p  01    re 

3  O    "g 


re 
re 
►.* 

3-    ft    ■« 

g  i-i  re 
P-  o  p^ 
o 


CTQ 

*3 
P 
1 


cr 
re 

"i 


p 

3 
P' 

cr 
re    5. 

§   B 
<   p 

re    X 


>-  /^  *= 

f*  2  re 

p  B  p 

3  p  i^ 

""  crT3 

»-*5  ^  re 

r^  g.  re 

^  ft  c. 

"-"  ^.  B^ 

3  01  re 

re'  2.  3 


cr 
P    ^ 

5  p" 

^  re 


3-  2  e  ET  SI' 


p 

"O 

5" 

?? 

r*- 

p_ 

re 

a' 

•-4 

o_ 

re 

p" 

•;<1 

c-t 

P 

re 

3 

P^ 

O 

re    K 

re    P 


re    2 

CL    P- 
P     '<' 


a    P    B 
B   -      3 


p   —   — 
e;  j5  — 

p^  p 

ft    a 

P-   -^ 


B"  B 


v;    _ 

3 
re 

o  5 

2.  S 

►1  p 

re  Z 


01  cr 

re  -) 

't.l 

p  Ol 

ri-  3 

cr  B 

re  g 

"  re 

5"  c 

o  »= 

"^  >t3 

Et  3 

re  re 

re  "ji 

3  c 

—  >i 

P  3 


►:.   re 

CTQ     p 

«*  P    E 


=■  ^  r  § 


p.  p    01        s.  'a  ►<    "    ~ 


re 


B   ?■ 


c 

re    re 
o    o 


w;  3 

cr  c 

<rt-  re 

2.  g 

C.  01 

re 


o 

01 

re 


3   «  ft 


01 

■   re 

tR     3 

I—  re 
re    B 


cr 

" 

re 

3 

3 

3 

re 

re 

re 

c_ 

/■i 

cr 

3" 

o 

re 

15 

re 

re 
re 


re  *3 


3        .?■ 


?r 


o 
"1 


s  ^ 
K   2. 

re    tn 

01 

3     p 

Ej    p. 


P      3- 

P      g 
01     E^ 


O 


P      ^. 


V  Ol 

^  B 

re  o 

2.  B 

N  a, 

re  I 


H 
H 

Q 

M 


a 


a 

o 
d 

a 


o 
» 

W 
o 
'^ 

SI 


PLATE   I. 


.5^ 


i ' 


^  ;>,:% 


/ 


DEATH    I'.V    HANGING.  205 

incr  •  it  may  perhaps  be  bitten  and  bleed i iiu  ;  bbuul  may  be  found 
emeryintj:  from  the  nose  and  ears.  The  hands  and  arms  are  livid  and 
swollen,  iiiid  the  tingers  may  I)e  so  tightly  clenched  that  the  nails  are 
found  wounding  the  palms.  The  limbs  and  feet  are  livid  and  swollen  ; 
the  genitals  are  large,  and  evidences  of  the  ex])ulsion  of  semen  and 
urine  may  be  encountered,  as  well  as  of  the  expulsion  of  feces  from  the 
anus.  Hemorrhoids  may  be  found  })romiuent  and  bleeding.  The  time 
of  appearance  of  rigor  mortis  depends  largely  n])on  conditions  of  bodily 
exertion  prior  to  the  hanging  and  the  severity  of  the  convulsive  stage ; 
as  a  rule,  it  does  not  come  on  for  one  or  two  hours  after  death,  but  may 
be  inuuediate. 

Dissection  of  the  neck  usually  shows  the  tissues  immediately  beneath 
the  ligature  to  be  compressed  and  bloodless  ;  but,  as  might  be  expected 
from  the  probable  injury  to  the  smaller  vessels,  Avheu  nuich  violence 
has  accompanied  the  process  and  death  has  l)een  gradual,  as  when  there 
have  been  a  decided  drop  and  death  by  asphyxia,  interstitial  hemorrhages 
of  variable  extent  are  found  in  and  about  the  line  of  compression,  just 
as  in  throttling  by  ligature. 

In  consequence  of  the  violence  of  the  fall,  lacerations  are  not  infre- 
quent. The  sternocleidomastoid  muscle  is  frequently  the  seat  of  such 
injury,  and  occasionally  the  inner  coats  of  the  carotid  arteries  are 
similarly  torn.  This  laceration  of  the  carotids  has  been  ascribed  to  the 
force  of  compression  by  the  ligature,  just  as  in  the  ordinary  surgical 
operation  of  ligation  of  an  artery  the  inner  coat  is  usually  severed ;  the 
great  difference  of  degree  and  completeness  of  compression,  and  the  fact 
that  these  vascular  tears  are  usually  met  below  the  level  of  the  ligature 
about  the  neck  and  not  upon  exactly  the  same  level,  do  not  afford  evi- 
dence of  such  a  view,  and  render  it  probable  that  they  are  entirely  the 
result  of  the  sudden  stretching"  force  in  the  fall.  Degenerative  states, 
such  as  atheroma,  favor  the  occurrence  of  such  an  accident.  The  exten- 
sion of  blood  between  the  coats  of  the  vessel-wall  at  the  place  of  rupture 
is  to  be  regarded  as  indicative  of  the  existence  of  circulation  at  the 
time  of  and  innnediately  after  the  injury.  In  a  small  proportion  of 
cases,  dependent  on  the  position  of  the  ligature  and  the  force  occurring 
in  the  process,  the  hyoid  bone  is  found  broken,  usually  in  its  larger 
cornua.  The  thvrohvoid  ligament  may  be  found  lacerated.  Disloca- 
tions  or  actual  fractures  of  the  thyroid  or  cricoid  eartih-gx's  are  occa- 
sionally encountered,  or  rarely  dislocations  of  the  arytenoid  cartilages. 
Occasionally,  especially  in  judicial  hangings,  dislocations  of  vertebra?, 
with  or  without  actual  fracture,  are  found.  Most  fre(inently  this  obtains 
in  case  of  the  odontoid  process  of  the  axis  or  as  a  dislocation  of  the 
axis  from  the  third  vertebra.  In  either  case,  of  fracture  or  dislocation 
or  both,  considerable  damage  is  likely  to  be  found  in  the  surrounding- 
tissues.  These  are  often  the  seat  of  hemorrhage,  and  the  membranes 
of  the  cord  and  the  cord  itself,  by  ])ressure  and  extension,  are  sometimes 
seriously  lacerated.  By  transmission  of  the  force  occasionallv  a  demon- 
strable injury  is  produced  in  the  medulla.  It  is  manifestly  impossible 
to  indicate  any  exact  projxirtion  of   cases  in   which   such   lesions  are 


206  DEATH    FROM    ASPHYXIA. 

encountered,  inasmuch  as  the  factors  for  their  production  vary  Avith  the 
mode  of  procedure ;  they  are,  however,  most  frequent  in  judicial  hang- 
ings, and  occur  but  rarely  in  cases  of  suicide. 

Upon  opening  the  larynx  and  trachea  the  mucous  membrane  of  these 
passages,  particularly  in  cases  of  hanging  with  violence,  is  found  suf- 
fused and  reddened,  occasionally  lacerated,  at  and  near  the  level  of  the 
ligature,  and  at  times  small  hemorrhages  are  found  upon  the  surface  of 
the  membrane.  There  is  usually  also  a  diffuse  hyperemia  of  the  entire 
respiratory  mucous  membranes,  and  there  may  be  considerable  mucous 
secretion  upon  the  surface.  When  the  strangulation  has  been  incom- 
plete, this  mucus  may  be  more  or  less  frotliy,  from  the  partially  success- 
ful efforts  to  breathe.  The  lungs  are  found  in  a  condition  similar  to 
those  seen  in  cases  of  throttling  by  a  ligature,  usually  deeply  congested, 
especially  in  dependent  parts,  sometimes  emphysematous  and  compara- 
tively free  from  blood.  Ecchymoses  beneath  the  pleurae  and  hemor- 
rhages into  the  tissues  of  the  lungs  are  seen,  Init  not  so  frequently  as  in 
throttling.  The  heart  is  usually  distended  witli  blood  in  the  right  side. 
The  left  heart  is  comparatively  empty.  When  both  sides  contain  blood, 
the  inference  is  warranted  that  death  took  place  from  syncope  rather 
than  asphyxia.  Subpericardial  hemorrhages  are  hot  so  frequent  as  in 
throttling,  and,  as  a  rule,  the  pericardial  sac  contains  but  little  serum. 

The  blood,  as  in  other  cases  of  asjjhyxia,  is  usually  found  in  the 
venous  rather  than  in  the  arterial  circulation,  and  is  dark  and  fluid. 
There  are  few  clots,  and  these  are  small,  being  found  in  the  heart  or 
elsewhere.  The  alxlominal  viscera  are  congested  and  dark  in  color. 
This  appearance  is  more  marked  if  suspension  has  been  prolonged. 
The  brain  is  usually  moderately  congested  in  the  venous  circulation,  Init 
rarely  extremely  so.  Sometimes,  however,  it  is  highly  hyperemic,  and 
in  a  very  small  proportion  of  cases — less  than  1  per  cent. — actual  hem- 
orrhages exist.  This  relative  absence  of  deep  congestion  is  probably  to 
be  accounted  for  by  the  drainage  of  the  blood  after  cessation  of  circula- 
tion into  the  face  and  neck,  on  account  of  the  position  of  the  head.  In 
cases  where  death  has  taken  place  by  immediate  circulatory  failure, 
corresponding  with  the  pallor  of  the  face  in  the  same  examples,  the 
brain  may  be  found  actually  anemic.  It  is  possible  that  if  the  body 
has  been  lying  with  head  lowered  for  a  time  before  the  brain  is 
examined,  some  return  flow  of  blood  to  its  dependent  parts  may  mask 
to  some  extent  the  real   state. 

Treatment  of  Strangulation. — In  all  cases  of  strangulation  the 
plan  of  treatment  is  about  the  same.  All  impediments  to  respiration 
must  be  removed  at  once.  If  in  suspension,  the  body  must  be  released 
instantly,  any  ligature  removed,  and  all  constrictions  about  the  neck  or 
body  by  clothing  loosened.  Artificial  respiration  must  be  applied 
immediately,  and  it  is  often  required  to  be  continued  for  several  hours. 
The  stagnant  circulation  is  best  relieved  by  moderate  blood-letting  and 
friction  of  the  surface.  Cardiac  stimulants  should  be  administered 
freely  hypodermically  ;  and  stimulation  of  the  sympathetic  nerves  by 
foradism  or  galvanism  tried.     Tracheotomy  below  the  level  of  the  com- 


DEATH    P.Y    IIAXGING.  207 

pression  should  be  performed  if,  fnua  swcHinu:  of  the  tissues  or  fracture 
or  dislocatioH,  much  impediment  to  respiration  exists.  Resuscitation  is 
rarely  successful  after  respiratory  etibrt  has  ceased,  l)ut  the  possibility 
of  a  favorable  ro-nb  remains  as  long  as  the  circulation  eontiiuies. 

Legal  Considerations. — In  but  few  cases  where  the  eireumstanees 
and  surrounding  evidence  agree  witii  the  postmortem  appearances  can  a 
reasonable  doubt  as  to  death  by  hanging  arise.  Yet  it  must  not  be 
forgotten  that  a  body  suspended  inunediately  after  death  may  present 
many  of  the  mark-;  caused  l)y  lianging  in  life,  and  that  such  a  ])rocedure 
might  be  resorted  to  in  order  to  ])revent  suspicion  of  other  modes  of 
destruction.  Thus  the  furrow  of  compression  by  the  ligature,  and  its 
drv,  leathery  appearance  can  uncpiestionably  be  produced,  as  proved  by 
experiment  upon  cadavers,  by  suspension  within  an  hour  or  two  after 
death ;  and  even  the  severer  cervical  injuries,  as  fracture  of  the  liyoid 
bone  or  of  the  larynx,  or  fracture  or  dislocation  of  tlie  cervical  vertebne, 
may  likewise  result  from  postmortem  hanging.  In  such  cases,  from  the 
recognition  of  external  marks  of  violence,  improbable  from  death  by 
hanging  alone,  from  the  absence  of  decided  hemorrhage  about  sites  of 
lesions  in  the  deeper  parts  of  the  neck  from  hanging,  from  the  relatively 
imcongested  ap]iearance  of  the  lower  l)order  of  the  groove  of  com- 
pression, and  the  tiiilure  of  the  usual  internal  evidences  of  asphyxiation, 
it  is  sometimes  possible  to  affirm  that  suspension  was  performed  after, 
rather  than  before,  death.  However,  the  value  of  tiie  absence  of  the 
internal  signs  of  asphyxiation  fails  in  these  cases  when  the  cervical 
lesions  point  to  a  ])rol>abilitv  of  immediate  death  from  syncope  after  the 
drop. 

Cases,  therefore,  may  present  themselves  in  which  medical  testimony 
alone  must  fail  in  our  present  knowledge  clearly  to  establish  one  or  the 
other  side  of  this  question.  Often,  however,  the  collateral  evidence  in 
relation  to  the  mode  of  attachment  of  the  ligature,  or  marks  of  varicnis 
kinds  (as  blood-stains)  upon  the  latter,  or  upon  the  person  of  the  victim, 
or  in  the  vicinitv  of  the  bodv,  mav  supplv  the  deficiencv  and  render  the 
problem  reasonably  clear. 

The  determination  of  death  by  hanging  from  death  by  other  forms 
of  asphyxiation,  especially  of  other  forms  of  strangulation,  when  the 
circumstances  siUTotinding  the  l)ody  when  discovered  allow  such  ques- 
tion, is  likewise  often  difficult.  Here  the  special  appearances  about  the 
neck  constitute  the  most  available  means  of  distinction.  The  peculiar 
marks  of  the  fingers  and  thuml^s  in  the  anterolateral  regions,  over  the 
respiratory  passages,  when  throttling  has  been  jierformed  by  hand  ;  the 
complete  and  horizontally  arranged  furrow  from  the  ligature  in  throt- 
tling by  ligature  are  here  of  great  import,  in  contrast  to  the  usually 
oblique  line  of  compression,  often  incomplete  near  the  ])osition  of  the 
knot,  in  death  by  hanging.  As  most  cases  of  hanging  with  a  drop  of 
any  length  are  instances  of  judicial  execution,  under  other  circumstances 
the  appearance  of  sugo'illations  in  the  groove  and  along  its  borders, 
interstitial  hemorrhages  in  the  dee])er  tissues  beneath  the  line  of  the  liga- 
ture or  marked  injury  to  the  larynx  and  trachea  must  speak  rather  for  the 


208  DEATH    FROM    ASPHYXIA. 

violence  of  murderous  throttling  than  for  ordinary  suicidal  suspension. 
Subpleural,  subpericardial  liemorrhages,  submucous  ecchymoses  of  the 
stomach  and  intestine,  and  cerebral  apoplexies  are  more  frequent  in 
throttling  and  suffocation  than  in  hanging ;  and  marks  of  violence  upon 
the  body  exerted  to  hasten  death,  as  by  kneeling  on  the  chest  or 
abdomen,  are  more  likely  to  be  found  when  death  has  occurred  from 
throttling.  Yet  the  entire  absence  of  any  mark  upon  the  neck  or  else- 
where in  either  case  must  not  be  forgotten  as  possible,  and  collateral 
evidence  therefore  not  neglected. 

Aside  from  legal  executions,  hanging  is  almost  always  suicidal. 
Among  suicides  this  method  stands  easily  first — of  25,737  suicides 
analyzed  by  Briand  and  Chaude,  11,608  are  credited  to  strangulation 
by  hanging  and  throttling.  In  a  large  proportion  of  cases  the  absence 
of  any  evidence  implicating  persons  other  than  the  victim,  and  the 
existence  of  testimony  indicating  more  or  less  specifically  that  death 
was  self-inflicted,  relieve  the  necessity  of  further  legal  inquiry.  AVhen, 
however,  questions  arise,  an  answer  may  be  possibly  obtained  in  the 
condition  of  affairs  in  which  the  body  is  found,  but  not  in  any  particular 
lesions  in  the  body  itself.  Thus  it  would  manifestly  be  mipossible  that 
a  body  found  hanging  with  the  arms  pinioned  at  the  back  could 
have  come  into  such  a  state  without  the  interference  of  another  person. 
A  body  found  hanging  freely,  and  without  means  at  hand  whereby  the 
individual  had  ascended  at  least  high  enough  to  have  adjusted  the  loop, 
must  indicate,  in  the  absence  of  strong  conflicting  external  testimony, 
that  another  was  implicated  in  placing  it  in  such  position.  On  the 
other  hand,  the  inference  in  cases  of  incomplete  suspension,  in  the 
absence  of  conflicting  evidence,  is  of  suicide,  or,  in  rare  instances,  of 
accident.  The  absence  of  other  evidences  of  violence  upon  the  corpse 
or  in  the  vicinity  must  further  corroborate  such  a  view,  since  it  is 
scarcely  possible  that  a  homicide  could  be  perpetrated  by  such  means 
against  the  active  resistance  of  the  victim.  The  insignificance  of  the 
common  cervical  marks,  especially  of  the  deeper  structures,  is  sugges- 
tive of  suicide  rather  than  of  homicide ;  and  in  a  large  proportion  of 
cases  of  suicide,  with  the  exception,  perhaps,  of  slight  reddish  discolora- 
tion beneath  the  comparatively  loose  ligature  in  incomplete  suspension, 
thev  mav  be  entirely  absent. 

II.  DEATH  BY  CHOKING. 

By  this  term  is  meant  to  be  indicated  all  cases  of  fatal  asphyxia 
resulting  from  the  occlusion  of  the  air-passages  by  agencies  within  these 
passages  or  their  walls.  Such  obstructions  may  be  of  external  origin, 
solid,  liquid,  or  gaseous ;  or  may  arise  within  the  body  as  the  result  of 
disease,  as  tumors  of  the  larynx,  croupous  membranes,  edema  of  the 
larynx  or  trachea.  The  latter  group  is  essentially  natural  and  of  no 
especial  concern  to  the  legal  physician,  save  in  a  negative  sense. 

For  legal  purposes,  then,  the  foregoing  definition  may  be  modified  so 
as   to   include   only  those  cases  of   fatal   occlusion   of   the   respiratory 


CHOKINCJ    BY    SOIJDS.  209 

passages  as  may  be  induced  in  one  or  other  way  by  foreign  agencies 
introduced  within  these  passages.  Such  occhision  may  be  a  direct 
nieclianical  ])higging  or  filling  by  the  foreign  substance,  or  it  may  be  the 
result  of  a  laryngeal  spasm  or  spasm  of  the  glottis  induced  by  the 
irritation  from  such  an  external  substance  in  the  conrse  of  its  entrance 
into  these  passages.  The  compression  of  the  posterior,  yielding  wall 
of  the  larynx  and  trachea  by  some  lai'ge,  hard  mass  in  the  esophagus  is 
likewise  commonly  accepted  as  a  form  of  choking,  although  differing 
slightly  from  true  choking  or  occlusion. 

I.  Choking  by  Solids. — Almost  invariably  in  choking  by  a 
solid  mass  the  occurrence  is  accidental.  There  are  on  record  a  few 
instances  in  which  solid  substances,  as  corks,  handkerchiefs,  dirt,  and 
other  matters  have  been  forced  into  the  back  of  the  mouth  or  actually 
into  the  glottis  with  murderous  intent ;  and  suicidal  individuals,  espe- 
cially those  in  confinement — the  insane,  for  example — frecpiently  attempt 
to  take  their  lives  by  similar  means  and  are  occasionally  successful. 
Even  when  not  immediately  successful,  as  the  after-result  of  irritation 
of  the  epiglottis  or  rima  glottidis  by  a  foreign  mass  or  by  some  caustic 
material  which  may  have  been  taken  into  the  mouth  and  swallowed, 
but  prevented  from  destroying  life  directly  by  antidotes,  serious  closure 
from  swelling  of  the  tissues  may  endanger  life  or  actually  cause  asphyx- 
iation. Accidental  choking  may  occur  from  the  swallowing  of  too 
large  and  too  hard  a  bolus  of  food,  which,  jiressing  through  the  wall  of 
the  esophagus,  causes  compression  of  the  posterior  respiratory  wall,  and 
may  thus  actually  close  the  air-passages.  Sometimes  a  mass  of  food  too 
large  easily  to  engage  in  the  upper  part  of  the  esophagus  overlies  the 
epiglottis  or  the  opening  of  the  glottis  and  thus  prevents  inspiratory 
movement  of  the  air.  Or  smaller  bits  of  food  may,  especially  if  the 
epiglottis  is  destroyed  or  impaired  by  disease,  actually  get  into  the 
opening  of  the  glottis  and  close  it. 

Nails,  tacks,  buttons,  and  a  host  of  different  small  objects  have  been 
known  thus  to  enter  the  upper  respiratory  tract,  and  sometimes,  if  their 
size  permit,  pass  downward  into  one  or  the  other  bronchus,  usually  the 
right,  on  account  of  its  straight  direction  and  large  size.  Attempting 
to  speak  and  swallow  at  the  same  time,  or  attempting  to  cry  out  when 
some  small  foreign  sul)stance,  as  a  coin,  is  in  the  mouth,  endeavoring  to 
inhale  while  partially  vomited  matter  lies  in  the  pharynx,  such  condi- 
tions are  especially  liable  to  produce  such  an  accident.  From  insi)ira- 
tion  during  vomiting  the  autlior  has  known  a  lumbricoid  worm  to  gain 
entrance  to  the  larynx  and  destroy  life  by  asphyxiation. 

In  feeding  the  insane  through  an  esophageal  tube  with  fluid  or 
partially  fluid  food  the  possibility  of  inserting  tiie  tube  into  tiie  larvnx 
instead  of  the  gullet  should  be  kejit  constantly  in  mind,  as  accidental 
asphyxiation  is  possible  both  from  the  tube  itself  and  from  the  fluid 
which  is  poured  through  it  after  imj)roper  adjustment.  Deplorable 
accidents  of  this  sort  have  occurred  in  a  number  (»f  asylums,  and 
serious  inflammatory  after-results,  such  as  ins[)iration  j)neumonia,  have 
followed    the    entrance    of    very   small   quantities    of    such   fluid    food 

Vol.  I.— U 


210  DEATH    FROM    ASPHYXIA. 

material.  It  should  be  remembered,  also,  that  among  the  insane, 
especially  with  paretic  dements,  careless  habits  of  eating  and  more  or 
less  muscular  incoordination  in  swallowing  may,  with  unusual  fre- 
quency, cause  paroxysms  of  choking. 

Children,  from  their  frequent  habit  of  placing  various  articles  in  the 
mouth  in  the  midst  of  play  and  laughter,  are  frequently  subject  to 
accidental  choking,  a  sudden  inspiration  drawing  such  objects  into  the 
larynx.  The  sudden  sharp,  full  inspiration  following  a  slap  on  the 
back  may,  if  some  suitable  substance  be  in  the  mouth,  cause  its  with- 
drawal into  the  respiratory  passages.  There  exists  during  sleep  or  the 
unconsciousness  of  anesthesia  or  of  an  epileptic  attack,  especial  liability 
for  the  entrance  into  the  fauces  of  such  material  as  may  be  in  the 
mouth,  and  hundreds  of  different  substances  are  recorded  in  medical 
literature  as  having  thus  given  rise  to  choking  of  an  acute  or  ])rolonged 
type.  As  examples  may  be  enumerated  such  things  as  pieces  of  meat, 
bread,  or  other  food,  jiieces  of  nutshell,  teeth,  plates  of  artificial  teeth, 
tooth-picks,  bits  of  pencils,  buttons,  nails,  coins,  grains  of  various  sorts, 
worms,  flies,  corks,  etc. 

Symptoms. — Immediately  after  the  entrance  of  the  foreign  material, 
which,  it  should  be  added,  may  not  be  foreign  but  have  developed 
within  the  respiratory  passages — as,  for  exam])le,  pieces  of  false  mem- 
brane, a  small  tumor,  a  diseased  bronchial  gland,  or  something  of  the 
sort,  there  occurs  a  more  or  less  severe  paroxysm.  This  may  be  fatal 
immediately,  as  is  usually  the  case  in  instances  requiring  legal  consid- 
eration ;  but  the  attack  is  often  survived,  only  to  give  rise  to  subsequent 
paroxvsms  upon  every  change  of  position  of  the  foreign  mass,  each  with 
the  possibility  of  fatal  termination.  Or  a  reaction  of  varying  intensity, 
acuteness,  and  position,  such  as  pneumonia,  laryngeal  or  tracheal  catarrh 
or  ulceration,  the  formation  of  abscesses,  tuberculosis,  or  other  lesions 
of  similar  type,  may  occur,  even  without  further  acute  attack  of  respira- 
torv  interference,  and  end  fatally  possil)ly  years  later.  Certain  animal 
and  vegetable  bodies,  after  being  bathed  in  the  warm  moisture  of  the 
parts,  may  swell,  and  thus  give  rise  to  more  and  more  serious  symptoms 
of  asphyxiation  for  hours  after  their  entrance  into  the  larynx. 

For  the  purposes  of  the  present  discussion  these  various  after-effects 
may  be  dismissed  because  of  their  similarity  to  the  primary  effects  or 
because  they  have  little  judicial  application.  So,  also,  the  entrance  of 
such  small  objects  which,  on  account  of  their  size,  are  unable  to  produce 
a  fatal  occlusion  may  be  set  aside  as  not  germane  to  the  subject. 

If,  then,  in  swallowing  or  breathing,  such  an  accident  of  occlusion 
should  occur,  the  patient  is  at  once  seized  with  distress  and  apprehen- 
sion. The  demand  for  breath  is  almost  immediate  and  quickly  becomes 
violent.  If  sitting,  he  rises  with  a  rush,  grasps  his  throat  with  the 
hand,  stretches  out  the  neck,  and  gulps  to  endeavor  to  dislodge  the 
intruding  mass.  All  sorts  of  attitudes  and  contortions  are  attempted 
for  the  same  purpose,  and  the  most  violent  efforts  at  coughing  are 
exerted  involuntarily.  The  face,  at  first  pale,  shows  signs  of  agony, 
and  becomes  quickly  deeply  suffused  and  cyanosed.     The  eyes  become 


CHOKING    BY    SOLIDS.  211 

promiueiit,  the  mouth  is  open,  the  toii<i::ue  often  extended.  Saliva  drips 
from  the  mouth,  and  i'oani,  often  tin(i;ed  witli  hh)()d,  appears  at  the  lips. 
Vomiting  may  tal^c  plaee,  and  the  involuntary  diseharge  of  urine,  gas, 
or  feees.  Tiie  faee  is  bathed  with  ]M'rs])iration.  In  a  few  miiuites  the 
victim  falls  unconscious.  The  violent  play  of  the  respiratory  nuiseles 
continues  for  one  or  two  miiuites  and  then  ceases,  witii  perhaps  one  or 
two  gasping  efforts  subsequently.  The  pul>c,  at  first  (piiek  and  full, 
becomes  tumultuous  in  a  few  minutes,  and  then  gradually  diminishes  in 
force  and  fidness  and  becomes  weak  and  irregular,  ceasing  finally  in 
eight,  ten,  or  more  minutes.  With  it  the  life  of  the  unfortunate  one 
st<^ps. 

Just  as  in  other  forms  of  respiratory  interference  considerable  varia- 
tion may  be  manifested  in  individual  cases,  from  the  completeness  and 
suddenness  of  occlusion  and  from  the  natural  resistive  power  of  the 
individual.  Death  sometimes  is  immediate  from  syncope,  and  the 
countenance  remains  pale  and  placid  ;  or  if  the  occlusion  is  not  quite 
complete  and  the  patient  vigorous,  the  violence  of  respiratory  effort  and 
the  degree  of  facial  contortion  and  cyanosis  are  extreme. 

Postmortem  Appearances. — On  external  inspection  there  may  be 
an  entire  absence  of  any  signs  suggesting  death  by  asphyxiation.  The 
face  may  be  quite  normal  in  its  ap[>earance,  both  in  color  and  in  the 
composure  of  the  features.  Often,  however,  the  face  is  deeply  cyanosed, 
and  when  found,  the  eyes  are  open,  prominent,  staring,  with  widely 
dilated  pupils,  and  the  features  may  be  much  distorted.  The  absence 
of  local  impediment  to  the  passage  of  blood  to  the  tnudv,  however, 
permits  this  ap})earance  with  much  less  frequence  than  in  strangulation. 
The  pulmonary  stagnation  may,  however,  be  so  great,  and  the  distention 
of  the  right  heart  so  marked,  as  to  prevent  this  movement  from  the 
head  and  neck,  and  there  is,  therefore,  a  proportion  of  cases,  somewhat 
less  than  half,  in  wdiich  the  cyanotic  condition  of  the  countenance  is 
pronounced.  As  a  rule,  there  is  also  considerable  congestion  in  the 
upper  extremities.  Lividity  of  dependent  parts  is  marked.  Rigidity 
usually  comes  on  early.  On  examination  of  the  body  after  section  the 
right  heart  and  larger  veins  of  the  trunk  are  found  full  of  dark,  fluid 
blood,  the  left  side  and  anterior  system  being  relatively  bloodless.  The 
lungs  are  usually  deeply  congested,  often  marked  with  small  subpleural 
ecchymoses,  sometimes  emphysematous  along  the  borders.  There  may 
also  be  found  some  pericardial  ecchymoses.  In  those  patients  who  die 
quickly  from  cardiac  inhibition  or  syncope  these  a])i)(  arances  in  the  heart 
and  lungs  do  not  obtain.  The  heart  contains  blood,  j)artially  clotted,  in 
the  cavities  of  both  sides,  and  the  lungs  are  not  especially  hyjieremic — 
perhaps  they  may  be  actually  pale. 

On  examination  of  the  respiratory  passages  the  mucous  membrane 
throughout  is,  as  a  rule,  hyperemic,  and  there  is  considerable  mucous 
secretion,  with  perhaps  some  blood,  over  its  surface.  At  the  level  of 
the  foreign  bodv  the  membrane  is  usually  quite  red  and  swollen,  with 
possible  marks  of  injury  due  to  the  intruding  substance.  The  foreign 
substance  itself  may  be  found  anywhere  from  the  larynx  down  to  the 


212  DEATH    FROM    ASPHYXIA. 

bronchial  tubes  of  the  second  or  the  third  division,  although  in  the 
latter  case  it  is  not  likely  that  death  was  ra])id  in  its  onset,  and  there- 
fore not  likely  to  have  much  legal  interest.  Death  by  choking  is 
usually  caused  by  comparatively  large  objects,  which  ai'c  rarely  found 
below  the  larynx.  As  a  rule,  such  have  had  little  opportunity  to 
undergo  substantial  change.  When  the  objects  have  been  retained  a 
long  time,  they  may  be  found  more  or  less  disintegrated,  even  such  sub- 
stances as  silver  coins  undergoing  chemical  changes  into  the  sulphid, 
and  are  thus  recovered  or  expectorated  after  the  lapse  of  months. 

When  the  foreign  body  has  thus  been  retained  for  a  time  before  the 
fatal  paroxysm  of  asphyxia,  the  local  appearances  are  even  more  pro- 
nounced. The  mucous  membrane  in  the  vicinity  is  thickened,  often 
ulcerated  ;  there  may  be  abscesses  in  the  surrounding  tissues,  areas  of 
consolidation  in  the  lungs,  or  tuberculous  changes  of  various  types. 
In  acute  choking  the  brain  is  hypercmic  if  freshly  examined  ;  later  it 
is  normal,  except  in  the  dependent  portions,  to  which  fluids  gravitate. 

In  such  an  examination  there  is  nothing  characteristic  of  the  par- 
ticular mode  of  death  save  the  discovery,  w  situ,  of  the  cause  of  the 
occlusion  ;  the  general  features  are  common  to  other  forms  of  asphyxia. 

Treatment. — Prompt  action  is  necessary.  The  patient  should  be 
pounded  vigorously  on  the  back  in  order  to  dislodge  the  oflending 
material  either  mechanically  or  by  exciting  particularly  strong  res])ira- 
tory  efforts.  The  head  and  shoulders  should  be  lowered  face  downward, 
or  the  body  even  inverted  to  aid  by  gravity  the  expulsion  of  the  mass. 
With  the  hand  pro])erly  guarded  by  a  handkerchief,  the  finger  should 
be  inserted  into  tlie  mouth,  and  it  may  sometimes  succeed  in  removing 
the  substance  if  it  is  in  the  pharynx  or  above  the  edge  of  the  glottis. 
Should  such  efforts  succeed  early,  the  patient  usually  takes  a  long,  full 
inspiration,  and  the  impending  trouble  quickly  disappears,  leaving  the 
patient  prostrated  and  weak  for  a  time.  If  they  are  insufficient,  and 
if  instruments  for  the  observation  of  the  exact  position  of  the  obstruc- 
tion and  for  its  withdrawal  are  at  hand,  they  should  be  em]>loyed  at 
once ;  if  not,  tracheotomy  below  the  supposed  level  of  the  mass  shoidd 
be  performed  immediately.  When  the  patient  ,has  ceased  breathing, 
artificial  respiration  should  be  performed,  a  means  of  entrance  of  air 
having  been  provided,  and  the  usual  treatment  for  asphyxiation 
practised. 

Legal  Considerations. — Aside  from  choking  during  the  course  of  a 
natural  disease,  this  mode  of  death  is  almost  invariably  accidental.  As 
a  means  of  suicide  it  is  rarely  resorted  to  save  in  desperation,  and  it  is 
hence  most  common  among  the  insane  of  asylums  and  prisons.  As  a 
means  of  homicide  it  is  rarer  still,  being  practically  impossible  unless 
the  victim  is  already  unconscious  and  helpless  from  prior  violence,  sleep, 
anesthesia,  or  similar  states. 

Careful  examination  for  the  existence  of  signs  of  such  violence  and 
inquiry  into  the  collateral  evidence  as  to  the  state  of  consciousness  at 
the  time  of  occlusion  may  give  inqiortant  results,  although  rarely  are 
they  positive.     The  mere  discovery  of  an  occluding  mass  in  the  respira- 


DEATH     I'.Y    sri'.MEnSION.  213 

tory  path  cannot  be  held  to  have  ]irove(l  death  by  such  occhision.  Snch 
a  mass  may  have  been  inserted,  at  least  into  the  fauces,  after  death,  to 
divert  suspicion,  as  has  been  recorded  in  a  few  instances.  It  is  neces- 
sary, therefore,  that  the  physician  establish  as  i'ully  as  possible  the 
absence  of  other  lesion  to  account  for  death,  and  the  existence  of  gen- 
eral signs  compatible  with  death  by  asj)iiyxiation  in  this  manner  before 
it  is  possible  to  render  a  verdict  of  death  by  choking.  It  is  to  be 
remembered  that  sometimes,  even  if  the  foreign  body  is  too  small  for 
complete  occlusion  at  the  level  of  its  lodgment,  it  may  induce,  by  irrita- 
tion, a  reflex  spasm  of  the  vocal  cords  or  of  tlie  muscular  liljers  in  the 
margin  of  the  glottis,  thus  leading  to  complete  closure,  at  least  for  a 
length  of  time  sufficient  to  precipitate  death  ;  and  that  the  mere  presence 
of  such  irritation  may  reflexly  cause  syncope,  irrespective  of  the  size  and 
character  of  the  irritant  substance. 

2.  Death  by  Submersion. — Death  by  submersion  or  drowning 
is  the  fatal  resiUt  of  asphyxiation  induced  by  complete  or  partial  sub- 
mersion of  the  subject  in  water  or  other  liquid  medium.  Such  a  defini- 
tion, however,  must  be  subject  to  various  exceptions  and  additions. 
While,  as  a  rule,  in  drowning  the  body  of  the  victim  is  completely  sur- 
rounded by  liquid,  cases  of  death  from  partial  submersion  are  not  infre- 
quent. Quite  recently  an  ei)ilei)ti(;  patient  of  the  writer's,  while  walk- 
ing upon  a  low  sandy  beach,  fell  in  a  paroxysm  with  face  down,  causing 
by  his  spasmodic  movements  a  small  excavation  of  an  inch  and  a  lialf 
in  depth  in  the  sand  beneath  his  face.  This  small  depression  quickly 
filled  with  water,  and  he  was  f  )und  dead  from  asphyxiation  in  tliis  posi- 
tion about  an  hour  or  more  after  the  occurrence. 

Of  course,  in  case  of  asphyxia  from  such  partial  submersion,  the 
respiratory  openings  must  be  included  in  the  part  submerged.  This 
latter  rule  does  not  of  necessity  prevail  in  cases  where  death  takes  place 
from  syncope,  individuals  fyom  time  to  time  being  known  to  succumb 
suddenly  upon  submersion  of  the  body,  but  with  the  respirator}-  o])en- 
ings  not  submerged.  Such  cases  are,  however,  rarely  confused  with 
real  drowning.  Moreover,  one  is  tempted  to  say  of  those  dying  in 
natural  surroundings  from  edema  of  the  lungs  that  they  drown  in  their 
own  juices — totally  apart  from  immersion  or  submersion. 

As  to  the  precise  mode  of  death  in  drowning,  asphyxiation  occurs  in 
over  90  per  cent.,  failure  of  circulation  from  syncope  being  responsible 
as  the  immediate  cause  of  death  in  perhaps  not  above  1  or  2  per  cent., 
while  combinations  of  respiratory  and  circulatory  failure  or  the  mediate 
influences  of  apoplexy  are  likewise  extremely  low.  Mackenzie,  of  Cal- 
cutta, from  an  analysis  of  over  300  cases  of  drowning  which  were 
examined  by  him  as  police  surgeon,  has  j)laced  death  by  asphyxia  as 
taking  place  in  over  97  per  cent.,  syncope  in  but  ^  of  1  per  cent.,  and 
asphyxia  and  apoplexy  combined  in  the  same  proportion.  About  2  ])er 
cent,  of  the  cases  examined  remained  undetermined  on  account  of  post- 
mortem changes.  It  is  ]>robable  that  these  proportions  would  show  a 
slightly  increased  proportion  of  cases  of  syncope  in  colder  climates,  from 


214  DEATH    FEOM    ASPHYXIA. 

the  greater  shock  to  the  nervous  system  of  the  unfortunate  in  commg  in 
sudden  contact  with  the  cold  water. 

Drowning'  was  at  one  time  a  legal  method  of  execution,  being  usually 
employed  in  case  of  women  and  minor  criminals  condemned  to  death. 
The  method  prevailed  in  England  until  the  early  part  of  the  seventeenth 
century,  and  was  in  vogue  in  a  few  of  the  continental  countries  of 
Europe  until  the  middle  of  the  following  century.  It  is  rarely  a 
measure  of  homicide  except  in  infanticide.  It  is  a  frequent  method  of 
suicide.  Analysis  of  large  numbers  of  instances  of  self-destruction  show 
its  employment  in  nearly  one-third  of  such  cases.  In  by  far  the 
greatest  proportion,  however,  it  is  the  result  of  accident.  Among  indi- 
viduals, of  course,  danger  of  drowning  upon  innnersion  is  extremely 
variable  from  the  ability  or  inability  to  swim  ;  but  such  ability  is  by 
no  means  a  guarantee  of  escape  from  such  consequences,  since  excellent 
swimmers  are  often  unable  to  sustain  the  fatigue  of  long  immersion, 
and  not  infrequently  succumb  suddenly  in  the  water  from  inabilitv,  from 
muscular  cramps,  or  from  syncopal  attacks. 

Individuals  who  possess  various  respiratory  defects,  such  as  stammer- 
ing or  asthma,  and  those  Avho  have  structural  or  serious  functional  dis- 
turbance of  the  circulatory  apparatus  or  its  nervous  mechanism,  are 
more  lial)le  to  drowning  upon  immersion  than  are  normal  individuals. 
In  general,  vigor,  health,  and  calnmess  of  mind,  other  things  being 
equal,  decidedly  diminish  the  danger  in  case  of  impending  drowning. 
Instances  of  drowning  occur  more  frequently  among  males  than  females, 
but  merely  because  of  their  more  frequent  exposure  to  its  conditions. 
Coldness  of  the  water  seems  to  increase  the  danger. 

Symptoms. — Observation  of  the  subject  would  indicate  that  several 
groups  of  cases  may  be  separated.  In  the  first  ])lace,  there  are  a  few 
cases  in  which,  when  sul)mersion  has  taken  place,  especially  if  it  has 
been  sudden  and  the  water  of  low  temperature,  death  is  found  to  ha\e 
taken  place  even  when  the  individual  is  immediately  rescued.  In  most 
of  such  cases  syncope  is  the  immediate  cause  of  deatli.  It  is  induced 
probably  by  the  severity  of  the  nervous  shock  or  by  individual  ineffi- 
ciency of  circulatory  power.  A  relatively  large  pro})ortion  of  this  group 
of  cases,  liowever,  may  be  resuscitated  if  the  attempt  is  promptly  and 
vigorously  made,  owing  to  the  relatively  moderate  alterations  which 
have  in  so  brief  a  ])eriod  of  time  been  effected.  It  is  probable,  as  stated 
by  Brouardel,  that  in  some  of  these  cases  death  occurs  from  a  nervous 
iidiibition  of  both  heart  and  lungs,  induced  by  the  stimulating  effect  of 
the  sudden  cold  upon  the  recurrent  laryngeal,  trigeminal,  and  other 
nerves  known  to  possess  sucli  inhibitory  reflexes. 

In  the  mucli  larger  group  of  cases  in  which  as]ihyxiation  is  the  direct 
mode  of  death  there  exist  at  least  two  j)ossil)le  methods  of  its  produc- 
tion. Thus  in  one  grou])  the  asj)hyxia  is  primarily  due  to  a  spasmodic 
closure  of  the  glottis  from  the  direct  irritation  of  the  water  entering 
through  the  mouth  and  nose,  and  about  to  penetrate  the  respiratory 
passages,  or  from  nervous  reflex  to  the  sudden  chilling  of  tlie  externrd 
surface  of  the  throat.      It  has  been  sho^vn  experimentally  that  laryngeal 


DEATH    JJY    SUBMERSION.  215 

spasm  may  be  induced  In-  mechanical  irritation  of  the  skin  over  the 
larvnx  and  anteromedian  portion  ot"  tiu^  neck.  In  this  g'rou[)  the  victim, 
t'allinii:  into  the  water,  usuuUv  sinks  at  once  and  remains  beh)w  the  siir- 
face.  As  in  the  otiier  eases  of  asphyxia,  unconsciousness  ensues  in 
the  course  of  some  seconds;  after  a  few  fntih'  convidsive  eiforts  to 
breathe  the  respiratory  attem])ts  cease,  and  after  some  minutes  the  heart 
stops.  Here,  after  a  mimite  or  two,  the  spasm  of  the  j^iottis  rekixes, 
while  there  are  but  few  and  feeble  inspiratory  efforts  and  but  little  water 
gains  entrance  into  the  respiratoi-y  tubes,  uidess  submersion  is  pro- 
longed, when  further  small  amounts  jnay  gradually  enter  as  a  post- 
mortem ])henomenon. 

In  by  far  the  greatest  numl)cr  of  cases,  however,  little  or  no  actual 
spasm  of  the  glottis  takes  place ;  and  as])hyxiation  oceurs  from  the 
actual  entrance  of  water  into  the  larynx,  trachea,  bronchi,  and  even 
the  terminal  saccules  of  the  lungs,  or  there  may  be  a  combination 
of  both  these  factors  of  respiratory  obstruction.  The  individual  hav- 
ing been  submerged  struggles  to  regain  the  surface  to  breathe.  As 
soon  as  the  surface  is  reached  he  attempts,  by  a  long  ins})iration,  to 
regain  his  breath  ;  but  is  likely  to  draw  a  small  amount  of  water  into 
the  larynx  with  the  air.  Owing  to  the  irritation  thus  caused,  violent 
expulsive  efforts,  partly  involuntary,  are  made  with  sputtering  and 
coughing.  The  real  effect  is  rather  to  diminish  the  air  in  the  lungs, 
accelerate  pulmonary  congestion,  and  non-aeration  of  the  blood,  and 
incidentally  to  increase  the  relative  weight  of  this  portion  of  the  body 
and  favor  further  sinking.  Considerable  water  is  likely  to  enter  the 
respiratory  ])aths  in  such  instances,  penetrating  at  once  to  the  air- 
vesicles  and  ])assing  by  osmotic  action  into  the  blood.  In  such  cases 
more  or  less  water  is  swallowed,  and  ])artly  fi"om  spasmodic  action  of 
the  diaphragm  the  contents  of  the  stomach  thus  dilated  are  likely  to  be 
regurgitated,  and  may  be  drawn  into  the  respiratory  tract  from  the 
pharynx.  The  struggle  inr  life  is  violent  ;  the  individual  grasps  at 
even  the  slightest  means  of  support,  and  often  in  the  blindness  of  his 
efforts  wounds  the  fingers  and  hands  in  manv  places.  Even  when  com- 
pletely submerged  and  upon  the  bottom,  he  wildly  and  futilely  tries  to 
lay  hold  of  surrounding  objects,  often  grasping  handfuls  of  the  mud 
about  him  and  frequently  getting  the  mud  an<l  sand  of  the  bottom 
beneath  the  finger-nails.  Small  (piantities  of  the  same  material  are 
likely  to  find  their  way  into  the  stomach  and  res))iratorv  j)aths  in  his 
mad  efforts  to  inspire  and  clear  the  obstruction  to  respiration.  After 
the  first  few  moments  of  respiratorv  obstruction,  which  is  usually  at  first 
incomplete,  the  face  becomes  cyanosed,  the  eyes  l)ulg(%  the  features 
become  contorted,  the  respiratory  movements  tunuiltuous  and  spasmodic, 
the  pulse  rapid  and  violent.  From  the  violence  of  his  efforts  the  con- 
tents of  the  bowel  and  l)ladder  mav  be  voided.  After  one  or  two,  or  at 
most  three  or  four,  minutes,  in  ordinary  cases,  respiration  has  ceased; 
but  for  a  number  of  minutes  (five  or  six  or  more)  the  heart  continues 
to  beat,  gradually  failing  in  strength,  rhythm,  and  ra|)idity,  and  usually 
stopping   in   systole.      The  entire  process   may   be  completed   in   three 


216  DEATH    FROM    ASPHYXIA. 

or  four  minutes,  or  may  be  prolonged  to  two  or  more  times  this 
period.  jj 

It  is  said  by  persons  Avho  have  been  rescued  from  drowning  that  in  1 

the  lirst  few  seconds  or  minutes  of  submersion  the  mind  possesses  the  ' 

activity  noted  in  other  forms  of  asphyxiation.  The  memories  of  years 
flood  the  mmd,  and  the  most  vivid  realization  of  the  impending  death 
and  its  consequences  rushes  to  mental  view.  The  head  seems  full  to 
bursting ;  a  dull  general  head  pain  is  realized  ;  there  is  a  roaring  or 
ringing  sound  in  the  ears.  The  sensation  of  want  of  breath  becomes 
absolutely  imperious,  and  in  spite  of  every  realization  of  its  futil- 
ity, inspiration  is  attempted  and  water  drawn  into  the  respiratory  tract. 
As  the  asphyxia  becomes  more  pronounced  the  mental  activity  gives 
place  to  a  feeling  of  resignation,  of  peace,  of  carelessness  of  results, 
and  in  a  moment  more  unconsciousness  supervenes.  In  this  form 
the  chance  of  resuscitation  is  much  less  than  in  either  of  the  former 

r 

varieties. 

Postmortem  Appearances. — Considerable  variation  is  possible  here, 
as  in  other  forms  of  asphyxia.  The  body  usually  becomes  rigid  early, 
within  the  first  hour,  especially  when  vigorous  struggling  has  taken 
place.  In  syncopal  cases,  however,  it  may  be  much  postponed.  The 
surface  of  the  skin  is  often  marked  by  "  goose-flesh,"  which,  being  the 
result  of  contraction  of  the  erector  pili  muscle-fibers  in  the  skin,  is  com- 
monly regarded  as  a  vital  action  and  as  evidence  of  the  submersion 
having  taken  place  during  life.  Immediate  submersion  of  the  body  after 
death  from  other  cause  may,  however,  be  attended  by  the  same  phenom- 
enon, especially  if  the  water  is  of  low  temperature.  On  the  other  hand, 
it  has  been  noted  that  Avhen  the  droM'ning  has  taken  place  in  compara- 
tively warm  water,  as  in  tropical  climates,  this  appearance  is  often 
wanting.  The  general  surface  of  the  body  is,  as  a  rule,  pale.  This  is 
to  be  expected,  from  the  action  of  the  cold  upon  the  general  surface,  and 
the  distention  of  the  larger  internal  venous  channels.  There  may  be 
small  patches  of  reddish  discoloration  in  variable  situations,  such  as 
occur  with  other  exposure  to  cold,  l)ut  they  are  unusual  and  of  slight 
decree.  The  face,  however,  in  most  cases  when  examined  early  after 
death,  if  death  has  actually  been  by  asphyxiation,  is  livid ;  while  in  all 
cases  of  syncopal  death  and  in  a  small  proportion  of  those  dead  from 
asphyxiation  (where  time,  position,  and  gravity  of  the  blood  and  a 
slight  degree  of  congestion  favored  drainage)  the  face  is  likely  to  be 
pale.  This  congested  condition  of  the  face  is  not  to  be  mistaken  for  the 
discoloration  of  putrefaction,  which  in  cases  of  drowning  generally  is 
first  manifested  about  the  face  and  neck  ;  this  latter  discoloration  is 
usually  of  a  deeper  and  more  violet  or  green  hue,  and  is  generally 
attended  l)y  a  greater  swelling  of  the  tissues.  When  the  drowning  has 
occurred  in  water  of  low  temperature,  and  especially  when  death  has 
come  on  rapidly  and  without  much  struggling,  the  face  is,  as  a  rule, 
pale.  This  is  owing  to  the  fact  that  drainage  of  the  superficial  tissues 
about  the  head  is  favored  by  the  constricting  influence  of  the  cold  water 
directly  in   contact,  and   because  the   body  is   not,  as  a   rule,  at  once 


DEATH    liY    teUii.MERSION.  .  217 

recovered.  In  the  majority  of  cases  the  face  is  placid.  The  eyes  are 
generally  only  partially  ckxsed,  and  the  pu])ils  dilated. 

Xot  infrccpiently,  as  observed  in  a  lariic  pr(iporti(Mi  of  several  hnn- 
dred  bodies  amuni;  those  dead  in  the  uTcat  Hood  at  Jolnistown  in  1889, 
in  those  cases  in  which  asphyxiation  was  gradual  and  accompanied  by 
severe  exertions,  conjunctival  ecchymoses  varying  in  degree  may  be 
found.  These  exist  entirely  apart  from  direct  violence.  The  testimony 
of  persons  resuscitated  or  rescued  before  unconsciousness  had  ensued, 
who  may  bear  the  same  peculiar  sign,  is  conclusive  on  this  point.  The 
ecchymoses  are  the  results  of  tiie  intense  congestion.  At  times  sucli 
suifusion  may  cover  the  entire  exposed  part  of  the  sclerotic  and  even 
extend  into  the  tissues  of  the  eyelid  on  the  dermal  surface.  Such  marks 
shonld  be  recognized  as  not  necessarily  the  result  of  external  violence. 
The  mouths  of  those  dead  from  drowning  are  commonly  partly  open  and 
the  tongues  in  normal  position,  occasionally  between  the  teeth.  The 
joints  are  nsnally  somewhat  ilexed,  either  from  the  contraction  of 
rigidity  being  more  powerful  in  the  Hexors  on  account  of  their  greater 
bulk  than  that  of  the  extensors,  or  rigid  in  a  position  of  flexion  assumed 
just  before  death.  Thus  often  the  hands  are  found  tightly  grasping 
various  objects  with  which  they  come  in  contact  in  the  struggle  of  the 
victim  ;  and  it  is  known  that,  at  times,  owing  to  a  tight  grip  of  grasses, 
roots,  or  other  matters  upon  the  bottom,  the  individual  has  been  held 
beneath  the  water  and  the  rapidly  appearing  rigidity  of  death  served  to 
maintain  the  grasp  and  keep  the  body  in  position  until  relaxatiou  from 
putrefactiou  has  set  the  corpse  free. 

In  examining  the  hands  note  should  be  made  of  the  character  of 
substances  thus  held  and  of  the  nnid  or  sand  found  beneath  the  nails, 
for  comparison  Avith  the  bottom  upon  which  the  person  met  his  death. 
So,  too,  the  hands  and  fingers  should  be  observed  for  excoriations,  which 
are  likely  to  be  produced  during  the  violent  struggling.  It  should  be 
remembered  that  after  a  few  days  there  is  usually  in  any  case  some 
dirty,  slimy  deposit  beneath  the  nails  and  in  other  protected  parts  of  the 
body,  and  this  bears  no  relation  with  the  material  scraped  up  during  the 
<leath  agony.  AVhen  stibmersion  has  extended  several  days  or  longer, 
the  palms  of  the  hands  and  soles  of  the  feet  are  generally  very  white 
and  shriveled,  and  the  epiderm  may  be  loose  from  the  coriuni  beneath. 
The  genitalia  are  tisually  found  more  or  less  contracted  and  small ;  but 
if  the  body  is  recovered  early  and  the  medium  is  not  cold,  the  reverse 
may  sometimes  be  encountered  and  the  penis  be  found  semi-erect. 

On  postmortem  section  the  blood  often  oozes  freely  from  the  slightest 
cut,  especially  when  death  has  been  recent.  The  heart  is  found,  as  in 
other  forms  of  asphyxia,  with  the  right  side  well  distended,  and  the 
left  small  and  empty.  The  blood  is  almost  always  found  iu  the  venous 
system,  dark  and  fluid.  Clots  are  less  rare  than  iu  the  ordinary  forms 
of  asphyxiation,  but  are  rarely  marked  or  large.  Iu  those  cases  dying 
of  syncope  the  left  side  of  the  heart  may  contain  blood,  and  clots 
may  exist  in  both  cavities.  As  a  rule,  there  is  a  slight  excess  of 
Huid  in   the  pericardial  sac  and  likewise  there  may  be  found  a  small 


218  DEATH    FROM    ASPHYXIA. 

quantity  in  the  pleural  cavities.  The  lungs  are  almost  invariably  large, 
rather  firm,  boggy,  and  crepitant.  They  are  usnally  uniformly  hyper- 
emic,  the  dependent  parts  of  a  deeper  hue  than  the  superior  parts  ;  and 
in  many  instances  the  latter  surfaces  before  section  have  a  dirty  grayish 
hue  from  a  relative  al)sence  of  blood  in  this  portion.  On  section,  how- 
ever, the  blood  drips  from  them  freely. 

On  examining  the  respiratory  passages  various  appearances  may  be 
found.  In  some  cases,  especially  in  those  dying  rapidly  or  immediately 
after  submersion,  nothing,  or  at  most  slight  hyperemia  of  the  mucous 
membrane  may  be  noted.  But  in  the  cases  dead  from  even  moderately 
gradual  asphyxia  there  is  to  be  found  a  variable  amount  of  water  in 
the  respiratory  tubes.  This  amount  is,  as  a  rule,  not  great, — a  few 
drams  or  ounces, — and  is  seen  mostly  in  the  trachea  and  larger  bron- 
chial tubes  ;  l)ut  it  is  probable  that  this  in  nowise  represents  the  real 
amount  of  such  fluid  which  may  have  entered  the  larynx.  The  condi- 
tion of  the  lungs  ;  the  degenerated  and  desquamated  alveolar  epithel- 
ium ;  the  hydremic  state  of  the  blood  upon  minute  examination  ;  the 
fact  that  the  fine  grit  and  mud  of  roiled  water  are  to  be  found  even  in 
the  smallest  ramifications  ^»f  the  air-passages, — the  fact  that  in  experi- 
mental drowning  of  animals  in  colored  waters  these  colors  have  been 
found  in  the  respiratory  terminal  areas, — all  point  to  the  fact  that  in 
such  condition  a  rapid  osmotic  process  takes  place  Avith  the  absorption 
of  a  very  material  portion  of  the  water  in+o  the  blood. 

Often  no  water  at  all  can  be  detected,  but  there  is  usually  a  quan 
tity  of  a  fine,  M'hite,  lather-like  froth  all  through  the  bronchial  system 
and  in  the  trachea  and  larynx.  This  is  su})posed  to  be  due  to  the 
violent  mingling  of  the  respiratory  air  with  the  water  entering  the  tract, 
and  is  hence  regarded  as  a  sign  that  death  took  place  by  a  slow  asphyx- 
iation from  submersion.  It  forms  more  freely  in  the  smaller  tubes, 
where  the  size  of  the  passage  com]>els  the  mixture  of  air  to  be  the  more 
thorough,  and  is  similar  to  the  fine  froth  sometimes  seen  in  these  ]>as- 
sages  in  death  by  pulmonary  edema.  Its  existence,  in  notable  amount, 
in  the  larger  passages,  is  therefore  significant  of  the  large  degree  of 
obstruction  by  fluid,  and  indicates  that  at  the  time  of  asphyxiation  these 
passages  were  largely  occupied  by  fluid.  This  froth  is  much  finer  than 
the  mucous  blebs  often  encountered  along  the  re^jiiratory  mucous  mem- 
branes. It  is  white  in  color,  and  may  ])ersist  for  ten  or  tAvelve  days 
after  drowning  if  the  body  remains  submerged.  In  addition  to  this 
froth  it  is  quite  conmion  to  find  the  mucous  membrane  more  or  less 
reddened.  In  some  instances  the  epiglottis  is  found  standing  almost 
erect  and  the  glottis  oj)en  ;  in  other  instances  tiie  former  is  normally 
adjusted.  In  examining  the  larynx,  trachea,  and  bronchi,  attention 
should  l)e  directed  to  the  existence  of  bits  of  foreign  matter,  as  mud  or 
sand,  carried  in  with  the  jienetrating  water. 

The  sub])leural  and  pericardial  hemorrhages  noted  in  other  forms  of 
asphyxia,  notably  in  throttling  and  in  any  nicchaiiical  suflbcation  in  the 
young,  are  occasionally  seen  in  cases  of  drowning,  but  are  infrequent.  The 
flu. id  in  the  pericardial  and  pleural  cavities  is  sometimes  tinged  with  blood. 


DEATir     BY    sni.MKKSIOX.  219 

Tlie  al)d<>minal  organs  are  almost  imifornily  oongosted  and  dark  in 
color.  The  stomach,  in  a  large  proiiortion  ot"  cases,  notably  those  dead 
by  a  slow,  struggling  form  of  asphyxiation,  is  likely  to  contain  more  or 
less  water,  swallowed  in  the  course  of  the  process.  This  is  not  invaria- 
ble by  anv  means,  and  in  order  to  determine  this  as  clearly  as  ]X)ssible, 
careful  examination  for  foreign  matter  known  to  exist  in  the  water 
surrounding  the  body  when  drowning,  as  bits  of  wood  or  straw,  nuid, 
and  sand,  should  be  made.  The  dia])hragm  is  often  found  markedly 
de])resscd,  probably  from  the  fulness  of  the  thoracic  cavity. 

In  the  third  variety  of  drowning,  and  to  a  less  degree  in  the 
second,  it  is  common  to  find  marked  venous  congestion  of  the  brain 
substance.  Very  rarely  actual  apoplectic  areas  exist.  In  those  cases 
where  the  head  has  remained  more  or  less  elevated  after  death,  much  of 
the  congestive  ap])earance  may  be  removed  by  gravitation  of  the  blood. 
A  sign  of  considerable  importance  may  sometimes  be  gained  by  aspira- 
tion of  the  middle  ear  as  a  small  quantity  of  fiuid  may  be  forced  into 
this  cavity,  especially  in  the  violence  and  confusion  of  ins])iration  and 
swidlowing,  with  the  mouth  I'uU  of  water.  It  is  not  known  that  M'ater 
can  force  its  own  way  into  this  cavity  after  death  ;  and  its  presence  is 
hence  regarded  as  important  evidence  that  submersion  was  ante- 
mortem. 

As  the  result  of  putrefaction,  the  signs  recorded  are  subject  to  more 
or  less  modification.  The  rapidity  of  apjiearance  of  putrefaction  depends 
upon  the  tcm])erature  of  the  water  and  depth  of  submersion,  as  well  as 
upon  individual  peculiarities  of  the  tissues  of  the  body  submerged  and 
the  character  of  water  in  which  the  corpse  is  submerged — whether  fresh, 
or  strongly  saline,  whether  stagnant  or  in  constant  motion.  Of  course, 
the  first  of  these  factors  is  determined  largely  by  the  season  and  climate. 
In  general,  it  may  l)e  said  that  these  signs  of  decomposition  in  water 
require  at  least  twice  the  time  as  in  air.  Putrefaction  in  these  cases,  as 
a  rule,  is  first  manifested  about  the  face  and  neck,  then  over  the  chest, 
groins,  thighs,  arms,  and  abdomen,  to  a  great  extent  a  reversal  of  the 
usual  order  of  putrefaction  in  the  air.  This  peculiarity  is,  however, 
more  apparent  than  real,  and  jirobably  depends  largely  upon  the  devel- 
opment of  considerable  quantities  of  gas  of  putrefaction  in  the  blood  in 
the  larger  internal  veins.  As  a  result  of  the  j^ressurc  thus  caused  the 
liquid  blood  is  fi)rced  into  the  capillary  areas  of  the  skin  and  mucous 
membranes  in  sufficient  quantity  to  give  rise  to  the  deep  discoloration 
of  the  early  stages  of  putrefaction.  The  surface  of  the  face  and  neck 
is  first  discolored  because  of  its  vascular  capacity,  while  for  a  contrary 
reason  the  abdominal  wall  is  late  in  being  thus  involved.  As  a  further 
consequence  of  this  phenomenon,  the  ])ortions  to  which  this  excess  of 
decomposing  fluid  tends  take  early  part  in  the  further  putrefving  changes. 
The  face  and  neck  hence  l)ecome  deeply  discolored  and  bloated,  both 
because  of  the  blood  in  the  tissues  and  because  of  the  gases  of  putrefac- 
tion which  develo]i  and  are  largely  retained  in  the  structures.  This 
swelling  of  the  countenance  entirely  obliterates  the  expression  and  often 
renders  the  features  unrecognizal)le. 


220  DEATH    FROM    ASPHYXIA. 

Owing  to  the  admixture  of  gases,  in  their  escape  from  the  respira- 
tory passages,  with  the  mucus  and  fluid  therein,  a  large  amount  of 
rather  coarse,  often  reddish-tinged  froth  is  formed,  and  may  frequently 
emerge  from  the  nostrils  and  niouth.  This  should  not  be  mistaken  for 
the  fine,  white,  lather-like  froth  already  described.  The  latter  is  likely 
to  have  disappeared  in  the  course  of  putrefaction,  and  at  best  is  not 
likely  to  persist  more  than  ten  or  twelve  days.  The  development  of 
gases  of  putrefaction  going  on  to  a  greater  or  less  extent  all  over  the 
body  causes  wide-spread  bloating  and  diminishes  the  relative  weight  of 
the  corpse,  which  in  consequence  becomes  lighter  than  water  and  rises 
to  the  surlace.  A  popular  idea  ascribes  an  influence  to  loud  sounds  in 
thus  causing  the  reappearance  of  bodies  submerged,  as  the  detonation 
of  cannon  or  the  roll  of  thunder.  The  real  cause  for  the  unquestioned 
relationship  is,  however,  not  in  the  sound  itself,  but  in  the  mechanical 
jar  or  tremor,  which  may  be  sufficient  to  dislodge  the  body  from  slight 
hindrances  to  its  ascent  to  the  surface.  The  greater  specific  gravity  of 
the  salt  water,  together  with  the  influence  of  the  motion  of  tides,  and, 
to  a  certain  extent,  of  the  waves,  induces  an  earlier  reapjiearance  of  the 
bodies  of  those  drowned  in  the  sea  than  when  submerged  in  quiet  fresh 
water.  There  are  some  collections  of  water,  such  as  Lake  Superior, 
from  which  it  is  said  submerged  bodies  do  not  reaj^pear  at  all.  These 
instances  are  probably  to  be  explained  upon  the  supposition  that  deep 
currents  sweep  the  corpse  away  from  the  locality  where  death  took 
place,  and  for  this  reason  it  is  not  discovered  before  complete  decom- 
position. It  may  be  said,  in  general,  that  the  bodies  of  those  drowned 
always  rise  to  the  surface  somewhere  and  at  some  time ;  but  that,  owing 
to  the  influences  of  currents  and  storms,  the  place  of  reappearance  is 
not  always  close  to  the  spot  where  drowning  occurred ;  and  that  inas- 
much as  all  circumstances  influencing  putrefaction  must  likewise  in- 
fluence the  phenomenon  of  ascent  to  the  surface,  a  great  variability  as 
to  the  time  must  be  accepted. 

The  season,  climate,  depth,  motion,  and  specific  gravity  of  the  water, 
as  well  as  certain  peculiarities  of  the  body,  such  as  the  amount  of 
adipose  deposit,  all  must  be  considered  in  estimation  of  the  probable 
time  in  any  given  case.  In  cold  climates,  especially  in  winter,  drowned 
bodies  do  not,  as  a  rule,  emerge  to  the  surfiice  of  the  water  until  the 
following  spring;  on  the  contrary,  in  warm  climates,  in  summer, 
bodies  may  rise  on  the  second  or  third  day — exceptionally  upon  the 
first. 

Examination  of  the  surfiice  of  such  bodies  will  show  that  when 
putrefaction  is  well  advanced,  and  probably  dependent  upon  the  relaxa- 
tion and  swelling  of  the  tissues  due  to  this  process,  the  cidis  anserina, 
or  "  goose-flesh,"  so  frequent  an  appearance  in  recent  cases,  is  wanting. 
Excoriations  and  chafings  of  the  skin  by  friction  of  the  surface  of  the 
body  upon  rocks  or  other  hard  substances  are  likely  to  be  encountered 
in  cases  where  submersion  has  been  prolonged  ;  these  marks  become 
dry,  hard,  brown,  and  parchment-like  a  short  time  after  exposure  to 
the  air.     Beneath  the  hand,  both  on  light  and  firm  pressure,  a  fine 


DEATH    BY    SUBMERSION.  221 

crepitation  due  to  the  oases  infiltrating^  the  subcutaneous  and  muscular 
tissues  can  usually  he  made  out.  Here  and  there,  especially  in  t!ie 
})alms  and   soles,   the  ei)idermis  is   readily  detachable  in  sheets. 

On  inierual  exaniiuation  the  evidences  oi"  i)utr(t:icti(>n  are  (juite  appa- 
rent. The  heart  and  laro-cr  vessels  are  not  so  full  of  blood  as  in  recent 
cases.  The  endocardiiun,  inner  coat  of  the  blood-vessels,  and  the 
mueous  nienibranes  of  both  the  resjiiratory  and  alimentary  canals  may 
be  stained  red  by  the  hemoglobin  (tf  the  decomposing  blood.  Bubbles 
of  gas  can  often  be  demonstrated  in  the  smaller  vessels,  and  the  intes- 
tinal canal  is  highly  distended  with  gas.  The  staining  referred  to  is 
not  limited  to  the  parts  mentioned,  but  is  likely  to  extend  more  or  less 
diffusely  throughout  highly  vascular  parts.  In  the  intestines  the  entire 
wall  is  often  so  deeply  reddened  as  to  suggest  an  active  inHannnatory 
process  ;  it  is,  however,  readily  distinguished  from  such,  and  may  be 
definitely  told  by  examination  under  the  microscope  without  the  use 
of  staining  reagents,  as  the  yellowish-red  tint  of  the  body  of  cellular 
elements  and  the  unstained  appearance  of  the  nucleus  will  quickly  gain 
the  attention. 

Treatment. — Attempts  to  resuscitate  those  apparently  dead  from 
drowning  are  more  successful  in  instances  of  those  becoming  imme- 
diately unconscious  when  falling  into  the  water,  and  in  those  in  whom 
death  has  apparently  taken  place  with  little  struggle,  and  asphyxia  has 
occurred  mostly  from  spasm  of  the  glottis — in  other  words,  in  all  those 
cases  in  which  little  water  has  penetrated  the  respiratory  passages. 
Instances  of  success  have  been  recorded  after  such  patients  have  been 
submerged  twenty  or  thirty  minutes,  but  where  submersion  has  lasted 
for  more  than  four  or  five  minutes,  there  is  usually  little  hope  of 
success ;  and  where  asphyxiation  has  been  general  and  much  water  has 
entered  the  respiratory  passages  in  the  wild  struggle  for  life,  attempts 
to  revive  almost  always  fail. 

As  soon  as  the  body  is  recovered  it  should  l)e  placed  in  position,  ^vith 
head  and  shoulders  depressed  and  face  downward,  to  favor  drainage  of 
fluid  from  the  mouth  and  respiratory  tract.  If  this  is  unsuccessful,  or 
as  soon  as  drainage,  which  is  aided  by  moderate  motion  of  the  body  and 
pressure  on  the  chest,  is  accomplished,  artificial  respiration  should  be 
instituted  and  persisted  in  for  hours  if  necessary.  Forcible  traction  of 
the  tongue  after  the  manner  of  Laborde,  about  eighteen  or  twenty  times 
a  minute,  synchronous  with  the  inspiratory  movement  of  the  artificial 
respiration,  may  be  of  distinct  aid  in  stimulating  the  respiratory  act. 
So,  also,  electric  stimulation  of  the  phrenic  nerves  may  be  of  service. 
In  addition  to  such  efforts  hyjiodermie  administration  of  cardiac  stinni- 
lants,  venesection,  the  external  employment  of  friction  and  heat  to  aid 
in  reestablishing  circulation  should  be  practised  as  required.  A  curious 
amnesia  often  follows  resuscitation,  the  entire  circumstance  of  drowning 
and  associated  events  often  being  a  complete  blank  to  the  ])aticnt. 
Constant  attention  should  be  given  th(>  patient  for  a  day  or  more  after 
resuscitation,  lest  sudden  syncope  set  in  and  unexpectedly  terminate  the 
patient's  life. 


222  DEATH    PROM    ASPHYXIA. 

Legal  Considerations. — For  the  legal  physician  there  are  three 
questions  of  particular  interest  in  this  connection  :  Was  death  actually 
due  to  submersion,  or  was  the  body  placed  in  the  water  after  death  from 
other  cause?  Was  submersion  accidental,  suicidal,  or  homicidal? 
How  long  has  the  body  been  in  the  water? 

In  the  determination  of  the  first  of  these  questions  it  should  be 
acknowledged  in  the  beginning  that  there  is  no  one  absolute  sign  of 
deatli  by  submersion.  The  best  evidence  is  obtained  by  the  combina- 
tion of  all  the  phenomena  already  detailed.  Of  the  individual  appear- 
ances, probalily  the  most  characteristic,  when  present,  is  the  lathery 
foam  found  in  the  larynx,  trachea,  and  bronchial  tubes.  It  is,  however, 
not  likely  to  remain  beyond  ten  or  twelve  days  after  submersion  when 
the  l)odv  is  in  the  water,  and  after  the  bodv  has  been  removed  from  the 
water  may  disappear  in  a  few  hours.  It  disappears  quickly,  also,  after 
putrefaction  has  set  in,  the  coarser,  tinged  froth  of  this  stage  entirely 
obliterating  it.  In  the  performance  of  the  autopsy  for  the  ])nrpose  of 
ol:)servation  of  this  feature  and  others  in  the  same  situation  the  jiarts 
should  be  so  opened  as  to  be  examined  in  f<itu. 

Perhaps  the  next  most  valuable  index  is  the  discovery  of  the 
presence  of  water  in  the  respiratory  tract  and  in  the  stomach,  and  the 
recognition  of  its  identity,  from  contained  particles  of  peculiar  char- 
acter, with  that  in  which  submersion  took  ])lace.  The  amount  of 
water  actually  found  in  the  lungs  and  trachea  is  rarely  large — usu- 
ally not  more  than  a  few  drams,  rarely  more  than  an  ounce  or  two. 
This,  however,  should  not  be  taken  as  an  indication  of  the  amount 
which  actually  entered  the  larynx,  since  a  considerable  part  is  dif- 
fused into  the  blood  throughout  the  lungs,  thus  contributing  to  the 
edema  and  to  the  size  of  these  organs.  Careful  search  for  particles 
of  extraneous  matter,  such  as  sand-grains,  mud,  or  vegetable  matter 
which  may  have  been  carried  in  with  the  Avater,  should  be  made  for  the 
purpose  of  identification  with  similar  matter  held  in  suspension  in  the 
water  in  which  such  body  has  apjiarently  been  drowned.  As  to  the 
water  in  the  stomach,  little  importance  can  be  attached  to  small  quanti- 
ties, since  it  may  have  Ijeen  swalloAved  naturally  shortly  before  death. 
If,  however,  more  than  half  a  pint  is  found,  or  M'hen  mud,  sand,  and 
bits  of  sticks  or  grasses  are  also  found,  it  may  be  presumed  to  have 
entered  during  the  death  struggle.  It  is  not  probable,  as  shown  by  the 
experiments  of  Tagerlund  and  otliers,  that  water  can  enter  into  these 
situations  after  death  except  under  considera1)le  pressure ;  and  the 
importance  of  the  sign  in  question  may  therefore  be  highly  regarded. 
Similarly,  when  present,  the  existence  of  water  in  the  middle  ear  is  of 
great  value  in  indicating  this  mode  of  death. 

Much  importance  has  been  placed  upon  the  presence  of  cutis  anserina 
by  some  writers.  This  may  often  be  found  in  death  from  other  causes, 
as  sometimes  in  death  by  freezing.  It  is,  moreover,  frequently  absent 
in  instances  where  death  from  submersion  took  place  in  water  of  mod- 
erately high  temperature,  and  regularly  disappears  after  putrefaction  is 
well  established.     While  the  large  size,  edema,  and  emphysema  of  the 


DEATH    HY    SUBMERSIOX.  223 

lungs  constitute  a  valuable  confirmatory  sio;n,  this  state  is  unquestionably 
influenced  lariivly  by  putrefaction,  and  might  be  closely  simulated  by 
putrefactive  changes  in  the  lungs  of  those  submerged  after  death. 

The  fluid  state  and  hydremic  condition  of  the  blood  ])ossess  similar 
importance  ;  the  blood,  however,  may  present  similar  gross  appearances 
in  other  foruis  of  asphyxiation  and  intoxication,  and  is  not  always  fluid, 
some  clots  frequently  being  found,  especially  in  those  dead  from  syn- 
cope, when  likewise  little  or  no  hydremia  prevails.  The  order  of  putre- 
facti(m  is  highlv  suggestive,  but  here  again  absolute  certainty  fails.  A 
similar  order  mav  occur  in  cases  where  the  blood  has  remained  fluid 
after  death,  as  in  other  forms  of  asphyxia. 

The  value  of  external  marks,  as  of  injury,  is  nuich  diminished  from 
the  fact  that  such  marks  might  be  produced  after  death  by  drowning, 
by  fish-  or  crab-bites,  by  chafing  or  beating  of  the  body  against  rocks, 
or  mav  have  existed  prior  to  the  time  of  death  and  have  had  no  influence 
in  its  production.  A  careful  consideration  of  such  marks,  as  to  their 
position,  character,  and  extent ;  the  existence  of  tumefaction  or  other 
signs  of  inflammation  about  them  ;  of  their  relation  with  deep-seated 
injuries  ;  with  the  general  postmortem  findings  and  with  any  possible 
external  circumstances  or  testimony,  will  usually  lead  without  much 
difficulty  to  their  true  significance. 

In  general,  then,  it  may  be  said  that,  with  the  modifications  and 
special  features  already  indicated,  death  by  drowning  may  be  predicated 
with  a  reasonable  degree  of  certainty  by  a  combination  of  these  signs 
u])on  the  body  found  in  a  fluid  medium — face  and  surface  pallid  or  dis- 
coIohmI,  especially  about  the  head  and  neck,  perhaps  in  the  latter  case 
much  s^v■ollen  ;  froth  of  a  peculiar  character,  water  and  foreign  particles 
in  the  respiratory  tract;  water  in  the  middle  ear  and  stomach;  lungs 
edematous  and  emphysematous  ;  diffuse  and  marked  congestion  of  lungs, 
alxlominal  viscera,  and  brain  ;  V)lood  dark  and  fluid,  and  present  mostly 
in  the  right  side  of  the  heart  and  in  the  venous  channels,  and  more  or 
less  postmortem  staining  by  hematogenous  pigment  of  the  tissues,  espe- 
cially the  endocardium,  lining  of  blood-vessels,  and  mucous  membranes 
of  the  respiratory  and  alimentary  tracts. 

In  endeavoring  to  determine  whetlier  the  drowning  was  accidental, 
suicidal,  or  homicidal,  the  main  reliance  must  be  placed  ny)on  collateral 
evidence.  Except  in  cases  of  children  and  those  known  to  have  been 
similarly  helpless  against  force  it  is  reasonable  to  regard  the  case  as 
either  accidental  or  suicidal,  rather  than  homicidal,  in  the  entire  absence 
of  signs  of  external  violence  from  the  body  found  dead  from  drowning. 
Homicide  is  not,  however,  entirely  eliminated,  since  it  is  jwssible  that 
even  the  most  able-bodied  might  at  times  be  thrown  by  an  unexpected 
push  into  the  water  \\ithout  the  least  sign  of  such  violence  having  been 
produced  upon  the  body.  On  the  other  hand,  when  distinct  signs  of 
violence,  such  as  severe  bruises,  cuts,  shot-wounds,  fractures  of  the 
skull,  imprisonment  in  sacks  or  by  bonds,  are  found,  the  first  thought 
naturally  refi'rs  the  death  to  an  author  other  than  the  dead.  Yet  it  is 
a  frequent  thing  for  suicides  to  double  their  efforts  at  self-destruction — 


224  DEATH    FROM    ASPHYXIA. 

to  shoot  themselves  while  in  such  position  that  when  falling  they  must 
be  precipitated  into  the  water  and  thus  insure  the  fatal  result ;  to  wound 
themselves  by  cut  or  stab  and  then  throw  themselves  into  the  water 
with  the  same  intent ;  even  to  fasten  weights  about  the  neck  or  else- 
where to  make  submersion  doubly  certain.  In  falling  into  the  water 
accidentally  or  as  a  result  of  suicidal  impulse,  the  body  might,  moreover, 
sustain  more  or  less  severe  injuries,  as  from  striking  upon  a  pier,  a  rock, 
a  log,  or  the  bottom.  Sharp  contact  with  the  surface  of  the  water  is 
capable  of  producing  splits  of  the  skin  and  underlying  tissues  which 
may  closely  resemble  cuts  by  some  dull  instrument,  fractures,  and  con- 
tusions. In  all  such  instances,  therefore,  aside  from  other  testimony, 
signs  of  injury  upon  the  body  or  of  disability  must  be  considered  in 
the  light  of  possible  self-production  or  of  accident  before  suspicions  of 
homicide  are  definitely  entertained.  In  all  cases  of  drowning,  moreover, 
the  history  of  preexisting  disability  of  any  sort,  of  epilepsy  or  insanity, 
as  favoring  accidental  submersion  or  suicide,  must  be  given  due  weight. 

Homicide  by  drowning,  save  in  case  of  infanticide,  is  rare,  and  is 
rarely  free  from  signs  of  the  violence  necessarily  employed.  Suicidal 
drowning  is,  however,  very  common,  upAvard  of  one-third  of  all  sui- 
cides bemg  accomplished  by  this  means.  In  cases  of  suspected  infanti- 
cide by  drowning,  care  should  be  exercised  to  determine  whether  the 
infant  had  been  born  alive  or  whether  a  still-born  infant  had  l)een  thrown 
into  the  water  for  purposes  of  concealment  or  economy.  The  usual 
hydrostatic  test  to  determine  distention  of  the  lungs  may  be  employed 
to  answer  this  question.  Evidence  of  strangling  or  suffocation  or  of 
other  means  of  destruction  should  likewise  be  sought  for,  drowning 
being  affirmed  only  in  the  absence  of  these  and  in  the  presence  of  the 
usual  signs  of  submersion. 

For  the  purpose  of  concealment  of  crime  it  is  not  an  infrequent 
practice  to  throw  murdered  bodies  into  the  water.  Serious  hindrance 
to  justice  mav  thus  sometimes  be  accomplished,  since  it  is  impossible  to 
declare  unreservedly  that  death  by  submersion  may  not  have  occurred 
in  absence  of  the  signs  just  detailed,  which  are  usually  present,  and 
because  putrefaction  may  in  great  measure  obscure  or  destroy  the  signs 
of  violence  employed.  In  cases  where  suspicion  of  such  practice  has 
arisen  it  should  be  remembered  that  the  group  of  signs  of  submersion 
cannot  be.  simulated  by  immersion  after  death,  except — and  then  not 
completely — in  case  of  death  l)y  some  other  mode  of  asphyxiation  ;  and 
when  sucii  signs  are  fully  established,  previous  violence  was  not  directly 
the  cause  of  death,  but  could  have  been  only  contributory.  In  cases 
where  such  signs  of  death  by  drowning  are  absent,  while  it  is  possible 
that  drowning  did  take  place,  it  is  impossible  to  make  affirmation  upon 
this  point,  and  the  importance  of  the  evidences  of  violence,  together 
with  the  collateral  testimony,  must  govern  the  decision.  As  a  general 
rule,  cuts  and  similar  wounds  produced  before  death  and  submersion 
will  retain  evidences  of  blood  coagula ;  while  similar  lesions  occurring 
after  submersion,  even  though  before  the  actual  time  of  death,  will,  from 
the  action  of  the  water  on  the  escaping  blood,  be  free  from  such  coagula. 


DEATH    BY    SUBMERSION.  225 

Therefore,  in  the  determination  of  the  sij^nificance  of  wounds  and  abra- 
sions in  bodies  found  submerojed,  (hie  attention  to  tlie  condition  of  the 
surface  of  the  wound  may  establish  the  iact  of  ])roduction  before  sub- 
mersion or  during'  submersion,  a  decision,  when  possible,  often  of  extreme 
value  judicially.  Any  scab  or  suppuration  or  granulation  on  the  sur- 
face of  the  wound  certaiidy  indicates  its  existence  a  number  of  hours 
or  days  before  death.  The  value  of  all  these  evidences  is,  however, 
impaired  by  the  fact  that  they  can  be  detected  certainly  only  in  com- 
paratively fresh  bodies. 

In  the  determination  of  these  points,  as  well  as  in  the  establishment 
of  identity  in  individual  cases,  and  for  other  obvious  reasons,  it  is  often 
necessary  to  estimate  the  probable  duration  of  submersion.  It  is 
necessarily  impossible  to  give  any  exact  opinion  u])on  this  question, 
since  so  many  factors  exist  capable  of  modifying  the  basis  of  judgment. 
Whatever  opinion,  however,  is  given,  such  must  depend  upon  the  alter- 
ations in  the  body  from  maceration  and  putrefaction,  where  previous 
knowledge  of  the  case  is  not  had.  An  approximate  idea  may  be  had 
from  the  following  statements,  originating  with  Devergie,  and  based 
upon  observations  made  during  the  severe  winter  of  1828-29  in  France. 
During  the  first  three  days  little  or  no  change  can  be  noted  from  the 
state  of  the  body  immediately  after  death.  Cadaveric  rigidity  is  usually 
pronounced.  On  the  third  or  fourth  day  the  epidermis  of  the  hands 
begins  to  blanch,  especially  over  the  thenar  and  hypothenar  eminences. 
From  the  fourth  to  the  eighth  day  the  remainder  of  the  palm  becomes 
white,  and  cadaveric  rigidity  disappears.  From  the  eighth  to  the  twelfth 
day  the  dorsal  side  of  the  hands  and  the  plantar  surface  of  the  feet 
become  blanched ;  the  face  becomes  flabby  and  slightly  discolored  if 
previously  ])allid.  By  the  fifteenth  day  the  palmar  epiderm  has  begun 
to  shrivel  and  to  show  peculiar  corrugations  ;  the  face  has  become  slightly 
swollen  and  dark  in  patches  ;  the  subcutaneous  tissue  over  the  chest  is 
red,  and  some  greenish  discoloration  is  likely  to  be  present  about  the 
upper  part  of  the  sternum.  At  the  end  of  the  first  month  the  epiderm 
of  the  palms  and  soles  is  very  white  and  shrunken,  just  as  if  from  pro- 
longed poulticing  ;  the  face  is  dark  and  red,  the  lips  and  eyelids  are  green- 
ish, the  hair  and  nails  are  adherent,  and  the  lungs  are  emphysematous. 
At  the  end  of  the  second  month  the  epiderm  of  the  hands  and  feet  is 
likely  to  be  more  or  less  detached  from  the  true  skin,  the  nails  adhering 
to  the  epiderm,  the  whole  somewhat  resembling  a  glove.  The  face 
Is  dark  and  nnieh  swollen,  and  the  lips  are  swollen  and  a])art ;  the  dis- 
coloration from  putrefaction  extends  to  the  shoulders,  upper  part  of  the 
abdomen,  sides,  and  about  the  jierineum.  The  heart  is  generally  nearly 
free  from  blood,  the  endocardium  of  the  side  which  contained  blood  at 
the  time  of  death  is  stained,  as  are  the  mucous  membranes  of  the  respi- 
ratory tract  and  alimentary  canal  ;  the  hollow  organs  and  vessels  gener- 
ally are  distended  with  gas.  By  the  end  of  two  and  a  half  months  the 
epiderm  and  nails  of  the  hands  are  conijiletely  detached  ;  the  epiderm  of 
the  feet  likewise,  but  the  nails  are  still  adherent;  the  putrefactive  dis- 
coloration has  extended  into  the  limbs.     By  the  end  of  another  month 

Vol.  I.— 15 


226  DEATH    FROM    ASPHYXIA. 

portions  of  the  scalp,  the  eyelids,  nose,  and  lips  may  be  partially  de- 
stroyed, and  the  nails  are  entirely  detached.  After  perhaps  another 
month  the  scalp  is  entirely  destroyed  and  the  skull-cap  denuded ; 
saponification  may  be  present  if  circumstances  favor. 

After  this  period  estimation  of  the  duration  of  the  submersion  is 
practically  impossible.  According  to  the  same  author,  quoted  by  Briand 
and  Chaude,  from  Avliose  work  these  statements  are  taken,  the  difference 
of  seasons  may  be  estimated  as  follows  in  the  judgment  of  their  effects 
upon  the  submerged  body  : 

In  summer  five  to  eieiht  hours'  submersion  corresponds  to  three  to  five  days  in  winter. 
"  "        twenty-four       "  "  "  "    four  to  eight    ''     "       " 

"         "        four  days'  "  "  "    fifteen  days  "       " 

"         "        ten  to  twelve  days'  "  "  "  four  to  six  weeks  "       " 

The  observations  as  to  the  persistence  of  the  peculiar  froth  in  the  respi- 
ratory tract  (lasting  ten  to  twelve  days  in  continued  submersion),  and  of 
the  cutis  anserina,  disappearing  in  from  three  to  four  weeks  in  water,  may 
be  of  assistance  in  the  formulation  of  an  opinion  as  to  this  matter.  How- 
pver,  it  must  be  kept  in  mind  that  such  statements  as  these  of  Devergie 
are  open  to  great  variation,  not  only  the  season  and  climate  and  conse- 
quent temperature  of  the  water,  but  the  depth  of  submersion,  the  char- 
acter of  the  water,  the  motion  of  the  water,  and  the  constitution  of  the 
body  submerged,  as  well  as  the  state  of  health,  etc.,  at  time  of  submer- 
sion, all  entering  as  factors  in  the  progress  of  these  changes. 

(c)  Death  from  Choking  by  Gaseous  Matter. — The  choking 
influences  of  gases  manifest  themselves  in  two  ways — either  by  directly 
provoking  a  spasm  of  the  glottis  from  irritation,  or  by  mere  exclusion 
of  oxygen  from  the  respiratory  tract.  The  most  common  of  gases  act- 
ing in  such  deleterious  fashion  is  carbon  dioxid  (carbonic  acid)  gas. 
Marsh-gas,  nitrogen,  and  hydrogen,  by  excluding  oxygen,  and  such  irri- 
tant gases  as  chlorin  or  ammonia,  by  causing  spasm  of  the  glottis,  may 
induce  asphyxiation  ;  but  many  which  act  thus  primarily  should  be 
classed  as  toxicants  in  their  further  effects. 

Carbonic  Acid  Gas  (Co^).^ — This  gas,  also  known  as  carbonic  oxid, 
carbon  dioxid,  and  "  choke-damp,"  is  the  result  of  complete  oxidation 
of  carbon.  It  arises  from  gradual  organic  decomposition,  especially  of 
vegetable  matter,  from  fermentations,  from  the  exhalations  of  animals, 
and  from  combustion  of  all  ordinary  inflammable  substances,  as  well  as 
from  chemical  decomposition  of  the  carbonates. 

It  is  a  colorless  gas,  with  higher  specific  gravity  than  that  of  air, 
and  therefore  has  a  tendency  to  collect  in  depressed  localities  in  unusual 
proportions.  Old  wells,  mines,  pits,  caves,  and  similar  situations  un- 
disturbed by  the  diffusing  influences  of  air-currents,  are  particularly 
likely  to  become  occupied  by  this  gas,  which  in  such  cases  is  very 
apt  to  have  been  formed  within  the  earth  and  brought  thither  per- 
haps along  some  water  course  or  merely  through  the  pores  of  the 
soil.  It  is  a  constituent  of  some  of  the  natural  gases  arising  from 
the  ground  in  connection  with  oil,  and  often  is  present  with  other 
1  Consult  also  the  chapter  on  "  Gaseous  Poisons'"  in  Vol.  II.  of  this  work. 


DEATH  FROM  CHOKING  BY  GASEOUS  MATTER.         227 

gases  ill  great  quantities  in  unrefined  oil.  It  is  found  in  the  bottoms 
of  fermentation  vats  which  have  been  nearly  emptied,  and  often 
accumulates  in  tlie  cellars  where  beer,  wine,  or  acetic  fermentation 
is  going  on  in  large  degree;  it  sometimes  develops  in  dangerous 
amoiuits  in  the  holds  of  vessels  carrying  some  I'ermentable  cargo.  It 
accumulates  in  badly  ventilated  rooms  in  which  large  numbers  of  human 
beings  or  animals  are  crowded,  or  in  which  large  numbers  of  lamps  or 
gas-lights  are  burned.  It  is  estimated  that  a  single  gas-light  of  ordi- 
narv  size  <;ivos  rise  to  five  or  six  times  the  amount  of  carbon  dioxid 
exhaled  bv  one  human  beinii"  in  the  same  time.  Another  source  of 
importance  is  in  the  household  fire ;  and  if  imperfect  draught  is  pro- 
vided and  poor  ventilation  of  rooms  obtains,  this  gas,  as  well  as 
carbon  monoxid  (CO),  may  accumulate  within  a  short  time  in  sufficient 
amount  to  ])e  iwsitivelv  dano;erous.  In  case  of  con fiay^rat ions  this 
gas  as  well  as  carbon  monoxid,  the  vapor  of  water,  and  other  gase- 
ous substances  are  produced,  and  together  may  collect  in  p(  )rtions  of  the 
building  in  Mhich  no  flames  exist,  and  lead  to  more  or  less  complete 
asphyxiation  of  persons  entering  these  apartments.  It  forms  one  of  the 
component  ]>arts  of  smoke,  and  plays  a  part  in  the  asphyxiation  by 
smoke,  which  occurs  so  often  in  connection  with  large  fires.  This 
gas  normally  exists  in  the  atmosphere  in  the  proportion  of  3  to  8 
parts  by  volume  to  10,000  of  air.  It  is  capable  of  producing  dele- 
terious results  upon  prolonged  inhalation  when  present  in  i  of  1  per 
cent,  by  volume  ;  and  when  it  has  accumulated  in  the  proportion  of  1 
per  cent.  l)y  volume  it  is  immediately  dangerous.  In  its  concentrated 
form  it  has  a  faint  sweet  odor  and  taste,  produces  a  decided  sense  of  irri- 
tation on  inhalation,  and  a  feeling  of  constriction  of  the  muscles  of  the 
throat  acting  as  directly  provocative  of  spasm  of  the  walls  of  the 
glottis.  The  voice  becomes  high-pitched,  even  whispering  is  induced, 
because  of  the  spasm  of  the  vocal  cords,  and  after  one  or  two  inhala- 
tions the  appearances  of  asphyxia  are  produced.  The  face  is  cyanosed, 
the  eyes  are  prominent,  the  mouth  is  open,  and  the  respiratory  muscles 
are  strained  ;  the  patient  clutches  at  his  neck  as  if  to  loosen  the  spasm  ; 
the  pulse  is  quick  and  bounding.  If  relief  is  not  given,  the  individual 
falls  unconscious  in  about  a  minute  or  even  less  time,  and  the  usual 
features  of  death  from  asphyxia  ensue.  To  luring  about  such  results  it 
is  not  necessary  tliat  the  gas  should  be  pure  ;  mixtures  of  1  per  cent,  or 
more  with  air  are  capable  of  inducing  much  the  same  result.  "When 
present  in  the  air  in  smaller  amount  it  is  more  gradually  ])roductive  of 
its  results,  acting  by  mechanically  taking  up  the  space  in  the  respiratory 
passages  which  should  be  free  to  ])roper  air.  There  is  a  feeling  of 
constriction  about  the  chest,  a  fulness  and  pain  in  the  head,  a  sense  of 
weakness  and  malaise,  usually  profuse  perspiration,  the  pulse  at  first  full 
and  quick,  but  later  becoming  rapidly  weak,  the  respiration  at  first 
shallow,  later  stertorous  and  slow,  sometimes  nausea  and  vomiting,  gid- 
diness, tinnitus  aurium,  somnolence,  and  the  gradual  oncome  of  uncon- 
sciousness. Death  commonly  takes  place  in  coma.  The  face  in  this 
latter  form  is  usually  pale,  but  may  occasionally  be  deeply  cyanosed. 


228  DEATH    FROM    ASPHYXIA. 

At  times  before  the  onset  of  unconsciousness  there  is  a  period  in  which 
Iialhicinations  and  even  active  insanity  are  manifested.  Death  from 
inhalation  of  air  containing  kirge  proportions  of  this  gas  properly  belong 
in  the  group  of  asphyxia  by  choking,  the  group  of  symptoms  and  the 
postmortem  signs  corresponding  closely  with  other  forms  of  asphyxia- 
tion ;  but  in  the  second  or  gradual  form  of  death  attributed  to  this 
agent  it  is  rare  that  other  influences  do  not  combine  in  such  measure  as 
to  modify  the  symptomatology,  mode  of  death,  and,  to  a  certain  extent, 
the  postmortem  findings.  Thus  in  case  of  suffocation  by  smoke  in  con- 
nection with  conflagrations  the  part  played  by  the  seriously  poisonous  gas, 
carbon  monoxid,  may  be  more  important  than  that  by  carbon  dioxid. 

In  situations  where  the  air  of  some  confined  space  becomes  contami- 
nated to  a  serious  degree  by  the  carbon  dioxid  from  the  exhalations  of 
the  crowded  occupants,  as  in  the  "black  hole  of  Calcutta"  in  1756, 
narrated  by  Percy,  it  cannot  be  doubted  that  other  exhalation  products, 
some  directly  toxic,  must  take  active  part  in  jiroducing  tlie  dangerous 
and  lethal  effects.  In  those  instances  of  gradual  asphyxiation,  more- 
over, the  poisoning  is  more  the  result  of  auto-asphyxiation  than  of 
the  gas  contained  in  the  inspired  air,  the  tension  of  the  gas  in  the  inhaled 
air  being  such  as  to  prevent  the  separation  of  the  carbon  dioxid  from 
the  blood.  Hence  the  effect  of  the  carbonic  acid  gas  in  these  instances 
is  one  rather  of  suffocation  than  of  choking,  the  accumulation  of  CO^  in 
the  blood  mechanically  preventmg  the  proper  oxygenation  of  the  hemo- 
globin and  producing  also  narcotic  influences  upon  the  nervous  system. 

Just  as  in  any  form  of  choking  or  strangulation,  death  in  a  ra^ykl 
jorm  may  sometimes  occur  from  syncope  rather  than  from  true  asphyxia- 
tion ;  and  there  occur,  therefore,  variable  features  in  the  postmortem 
appearances.  Usually  the  body  is  cyanosed,  especially  the  face  and 
neck.  The  blood  is  dark  and  uncoagulated,  and  present  mainly  in  the 
venous  circulation.  The  right  heart  is  distended,  the  left,  comparatively 
empty.  The  lungs,  abdominal  viscera,  and  brain  are  usually  deeply 
congested.  In  syncopal  death,  however,  the  face  is  likely  to  be  pale 
and  composed,  and  tlie  general  surface  of  the  body  is  white  ;  the  blood 
is  more  frequently  found  at  least  moderately  coagulated  and  present  in 
the  left  as  well  as  the  right  side  of  the  heart. 

In  case  of  death  from  entrance  of  the  gas  in  the  deeper  respiratory 
passages  the  influence  upon  the  appearance  of  the  blood  of  other  gases 
must  constantly  be  thought  of,  especially  that  of  CO,  wliich  may,  per- 
haps, also  have  been  present  in  the  atmosphere  inspired.  Generally  in 
these  cases,  when  the  carbonic  acid  gas  is  fully  and  widely  diffused 
through  the  tissues  and  fluids  of  the  corpse,  the  body-heat  and  rigidity 
are  likely  to  be  unusually  persistent,  and  putrefiiction  does  not  come  on 
readily.  The  face  is  usually  livid,  but  may  be  pale ;  the  countenance 
is  generally  calm. 

In  the  absence  of  gases  having  toxic  action  upon  the  blood,  as  CO, 
CN,  HjS,  and  others,  the  blood  is  almost  black,  usually  fluid,  but  some- 
times thick  and  partially  clotted.  For  purposes  of  determination  the 
blood  may  be  submitted  to  spectroscopic  examination,  when  the  peculiar 


dp:atii  by  suffocation.  229 

displacement  to  the  right  of  the  absorption  bands  at  D  and  E  should  be 
observed.  Or  the  carbon  dioxid  may  be  removed  from  the  carefully 
collected  blood  by  the  air-pump  or  by  displacement  in  an  atmosphere  of 
oxygen,  and  estimated  by  collection  in  a  solution  of  an  alkaline  hydrate 
as  a  carbonate.  In  the  ]>resence  of  the  toxic  gases,  as  of  CO  or  ON, 
the  blood  is  usually  of  a  bright-red  color,  and  spectroscopic  or  chemical 
examination  may  be  employed  to  determine  their  presence. 

In  all  cases  of  impending  death  from  carbonic  acid  gas  the  first 
necessity  is  the  plentiful  supply  of  oxygen.  For  this  purpose  the  patient 
should  be  removed  at  once  to  the  open  air  ;  inhalations  of  pure  oxygen 
may  be  employed.  Artificial  respiration  should  be  practised  and  per- 
sisted in  when  necessary ;  and  hypodermic  injections  of  circulatory 
stimulants,  especially  nitroglycerin,  as  recommended  by  Hoffman,  and 
strychnin  freely  administered.  The  surface  of  the  patient  should  be  sub- 
jected to  friction  to  aid  in  restoration  of  the  circulation  ;  and  cai'c  must  be 
taken  to  prevent  a  secondary  syncope  for  a  number  of  days  after  resuscitation. 

Death  by  this  means  is  almost  invariably  the  result  of  accident.  The 
victim  may  have  descended  into  a  well  for  the  purpose  of  cleaning  it ; 
or  into  an  old  mine-shaft  for  investigation  ;  or  has  perhaps  entered  a 
large  fermentation  vat  for  similar  reasons  ;  and  death  has  come  almost 
as  from  a  blow.  Appreciation  shoidd  follow  at  once  in  such  cases,  and 
chemical  examination  of  the  air  of  the  locality  and  an  endeavor  to 
establish  the  existence  of  an  excess  of  the  gas  in  the  blood  be  instituted. 
It  should  not  be  expected,  however,  that  a  greater  amount  of  the  anhy- 
drid  will  be  met  in  the  blood  of  such  cases  than  in  that  of  those  dying 
gradually  from  inhalation  of  the  gas.  On  the  contrary,  there  will  be 
less,  since  the  respiratory  act  is  more  quickly  overcome  and  there  is  less 
chance  for  the  accumulation  from  vital  processes  before  death. 

In  such  investigations,  as  well  as  for  precautionary  measures,  a 
lighted  candle  should  be  exposed  to  the  air  supposed  to  have  noxious 
properties,  and  if  the  fiame  is  extinguished  or  materially  diminished,  it 
may  be  concluded  that  life  cannot  be  maintained  therein.  Lime-water 
or  other  solution  of  an  alkaline  hydrate,  if  exposed  to  such  an  atmos- 
phere, soon  becomes  turbid  or  has  a  scum  formed  upon  the  surface  from 
the  formation  of  a  carbonate.  A  bit  of  moistened  blue  litnms  paper  is 
at  first  reddened,  and  later  bleached.  Quantitative  estimations  may  be 
readily  made  by  the  estimation  of  the  carbonates  formed  in  solutions  of 
alkaline  hydrates,  or  by  means  of  a  standard  solution  of  an  alkaline 
hydrate,  and  correction  for  the  nnused  alkali  by  oxalic  acid,  phenol- 
phthalein  being  employed  as  an  indicator.  It  should  be  remembered  that 
a  candle  will  burn  in  an  atmosphere  too  fully  charg(>d  with  this  gas  to 
permit  animal  life,  from  5  to  10  per  cent,  of  CO^  being  required  to 
extinguish  the  flame,  1  or  2  per  cent,  being  incompatible  with  life. 

m.  DEATH  BY  SUFFOCATION. 

The  term  suffocation  was  originally  a]>])lied  only  to  such  cases  of 
asphyxia  as  arose  in  consequence  of  disturbances  operative  internally  and 


230  DEATH    FROM    ASPHYXIA. 

below  the  larynx  (^suh,  faux,  -cis).  This  meaning  has,  however,  been 
entirely  lost,  and  the  common  application  of  the  term  at  present  includes 
all  cases  in  which  asphyxiation  results  from .  any  cause  preventing  the 
entrance  of  air  into  the  mouth  and  nostrils,  as  well  as  any  external 
obstruction  to  the  respiratory  movements  of  the  chest  and  abdomen 
sufficient  to  prevent  breathing,  and  also  the  toxic  and  mechanical  effects 
of  a  number  of  gases  preventing  hematosis.  For  convenience,  there- 
fore, it  may  be  considered  from  the  point  of  view  of  either  an  external 
or  internal  insufficiency  of  the  respiratory  process. 

(a)  SufFocation  from  Bxternal  Causes. — Instances  of  death 
from  such  cause  are  not  very  infrequent  and  may  claim  legal  considera- 
tion as  being  the  result  of  either  homicide  or  accident,  but  practically 
never  of  suicide.  The  most  common  metliod  of  homicidal  suffocation 
is  that  known  as  "  burking,"  so  named  from  the  famous  Burke,  who, 
with  his  comrade.  Hare,  in  a  number  of  instances  accomplished  murder 
in  this  manner.  Here  the  victim,  having  been  hurled  to  the  ground,  is 
held  do^vn  by  the  weight  of  the  murderer's  body,  which  at  the  same 
time  is  sufficient  to  interfere  seriously  with  the  chest  and  abdominal 
respiratory  movements.  The  criminal  holds  the  mouth  and  nose  shut 
with  one  hand  closely  applied,  while  with  the  other,  unless  otherwise 
required  by  the  victim's  struggles,  he  attempts  to  force  the  lower  close 
to  the  upper  jaw  and  thus  aid  in  eflFectually  closing  the  respiratory 
openings.  When  successfully  applied,  death  generally  follows  in  three 
or  four  minutes  with  all  the  usual  symptoms  of  other  forms  of  asphyxia- 
tion by  external  mechanical  means.  In  these  cases,  while  not  necessary 
to  the  accomplishment  of  the  murder,  pressure  upon  the  chest  and 
abdomen  doubtless  hastens  and  makes  more  certain  the  fatal  result. 
This  same  method  of  suffocation  or  smothering  is  sometimes  wilfully, 
and  frequently  unwittingly,  a  means  of  infanticide.  The  parent,  per- 
haps intentionally,  perhaps  unconsciously  from  drunkenness  or  from 
deep  natural  sleep,  "  overlies,"  as  the  term  goes,  the  young  infant  occu- 
pying the  same  bed,  completely  stifling  any  attempt  to  cry  and  prevent- 
ing all  respiratory  movements.  Of  course,  in  such  instances  the  hand 
is  not  applied  over  the  mouth  and  nose,  the  body  of  the  parent  generally 
performing  the  same  office.  Instead  of  the  hand  covering  the  respira- 
tory openings,  clothes,  bandages,  and  similar  objects  may  be  applied  for 
the  same  purpose.  In  a  number  of  instances  children  have  been  known 
to  have  been  smothered  by  being  too  closely  and  completely  covered 
about  the  face.  Mothers  have  been  known  to  smother  their  infants  by 
pressing  them  too  closely  to  the  breast  when  nursing.  Smothering  has 
resulted,  too,  by  individuals  falling  in  an  unconscious  condition  in,  or  being 
placed  purposely  in,  substances  which  occlude  the  mouth  and  nostrils,  as 
mud,  plaster,  ashes,  feathers,  grain,  or  like  material.  Thus,  intoxicated 
persons  or  epileptics  have  been  know  to  have  fallen  face  downward 
into  mud  and  suffered  death  from  suffocation.  Infants  have  been  buried 
alive  in  bran,  ashes,  feathers,  and  mud  with  the  same  result.  Several 
instances  are  recorded  where  an  insufficient  access  of  air  was  permitted 
in  making  plaster  casts  of  the  features  and  bust,  only  the  most  ener- 


SUFFOCATION    FROM    EXTERNAL    CAUSES.  231 

getic  relief  preventing;  death.  Instances  of  suffocation  in  crowds,  from 
the  difficulty  of  accumplishin<^  the  chest  and  alxloniinal  respiratory 
movements,  are  not  infrecpient  when  tlie  pressure  of  the  crowd  is  oreat ; 
and  this  is  materially  aided,  when  the  crowd  is  (;onlined,  by  the  effet^t  of 
the  excess  of  carbon  dioxid  and  other  products  of  exhalation. 

Individual  predisi)ositious  and  resistances  to  this  form  of  asphyxia- 
tion are  identical  with  those  already  considered  in  connection  with 
strantj^ulation. 

Symptoms. — The  course  of  events  in  all  these  varieties  of  suffoca- 
tion from  agencies  operating  externally  is  similar  to  that  mentioned  in 
the  discussion  of  strangulation,  except  that  the  effects  of  compression  of 
the  vessels  and  nerves  of*  the  neck  and  of  violence  to  the  tissues  of  the 
neck  and  spinal  cord  do  not  enter.  They  may,  therefore,  be  dismissed 
with  brief  enumeration.  In  cases  where  the  suffocative  obstruction  is 
applied  with  suddenness  and  much  violence  immediate  death  may  occur, 
as  in  strangulation,  from  cardiac  syncope.  Usually,  however,  a  number 
of  minutes  elapse  before  death  takes  place,  and  in  individual  instances, 
where  obstruction  to  respiration  is  incomplete,  this  period  may  be  much 
lengthened.  In  ordinary  cases,  immediately  following  the  application 
of  the  obstruction  to  the  mouth  and  nostrils,  there  ensues  a  momentary 
pause  in  which  the  victim  makes  no  effort  to  breathe.  Then  follows  the 
more  or  less  violent  struggle  for  breath.  The  face  becomes  purple  and 
almost  black  ;  the  eyes  protrude  ;  there  is  energetic  effort  of  the  muscles 
of  the  nose,  face,  neck,  and  chest.  The  victim  feels  an  overpowering 
demand  for  air  ;  the  head  feels  full  and  dully  pains  ;  the  ears  roar ;  the 
mind  becomes  extremely  active.  The  pulse  throbs  violently  and  wildly  ; 
the  whole  body  A\Tithes  in  the  violence  of  agony,  and  urine,  semen, 
feces,  and  gas  may  be  discharged.  There  come  on  rapidly  a  sense  of 
loss  of  strength,  relaxation,  helplessness,  indifference  of  result,  and 
unconsciousness.  The  respiratory  movements  become  weaker  and 
weaker,  and  in  two  or  three  minutes  cease ;  the  pulse  is  lost  more 
slowly,  continuing  to  beat  sometimes  for  many  minutes  after  respiratory 
movements  have  failed.  When  the  obstruction  is  of  such  a  nature  that 
it  may  enter  the  mouth  and  respiratory  passages,  as  in  case  of  mud  or 
ashes,  it  may  penetrate  the  nostrils  and  the  mouth,  may  be  swallowed 
and  even  be  drawn  into  the  larynx  and  trachea,  when  attempts  at 
coughing  and  the  reflexes  from  local  irritation  are  likely  to  add  to  the 
unha])])y  situation.  Only  when  the  nature  of  the  obstruction  permits, 
and  then  merely  at  the  beginning  of  the  struggle  for  breath,  are  there 
efforts  at  outcry,  limited  to  the  short  attempt  at  expiration.  AVhen  the 
obstruction  is  incomplete,  but  the  victim  is  unalile  to  free  himself,  the 
respiratory  efforts  grow  weaker  and  shallower,  more  and  more  irregular, 
accompanied  by  stertor,  and  finally  cease ;  sometimes  as  much  as  twenty 
or  thirty  minutes  elapse  before  the  end  is  reached. 

It  is  uncertain  whether  one  should  consider  in  this  connection  those 
cases  said  to  die  from  suffocation  from  close  confinement,  as  where  a 
living  person  is  entombed  in  a  small  space  in  a  mine,  or  beneath  a  mass' 
of  dirt  in   some  excavation  ;  where    a    living  person  has  been  buried 


232  DEATH    FROM    ASPHYXIA. 

inclosed  in  a  tight  coffin  and  covered  with  earth  ;  where,  by  some  mis- 
hap or  for  some  reason,  an  individual  is  shut  up  alive  in  a  close  closet 
or  in  a  chest.  The  results  seem  but  little  diiFerent  from  those  due  to 
the  direct  occlusion  of  the  respiratory  openings,  but  the  question  must 
arise  whether  in  reality  death  does  not  here  take  place  from  the  accumu- 
lation of  carbonic  acid  gas  and  the  toxic  influences  of  the  respiratory 
excreta.  There  are  few  data  to  go  by  save  those  derived  from  persons 
rescued  after  confinement  in  mines  or  in  such  places  as  the  famous 
"  black  hole  of  Calcutta"  or  the  experiences  of  persons  who  have  in 
crowds  been  confined  in  the  holds  of  vessels  for  a  number  of  hours  Avith 
all  the  hatches  closely  shut ;  the  symptoms  of  these  persons,  as  already 
mentioned  in  the  discussion  of  the  effects  of  carbonic  acid  gas,  uphold 
the  latter  idea.  In  fact,  when  carefully  regarded,  one  is  tempted  to 
give  great  weight  to  the  view  advanced  by  Fitz  that  all  forms  of 
mechanical  asphyxiation  are  in  rcalit}-  instances  of  the  effects  of  carbon 
dioxid  accumulated  with  other  deleterious  principles  in  the  blood  from 
failure  of  expulsion  through  the  lungs,  the  chemical  and  anatomic 
differences  being  circumstantial  and  the  results  of  sjiecial  conditions. 

Postmortem  Appearances. — As  might  be  expected,  there  are  here 
a  number  of  appearances  common  to  all  forms  of  mechanical  asphyxia- 
tion. The  face  and  neck  are  usually  darkly  cyanosed,  and  there  may 
be  evidence  of  hemorrhage  from  the  nose  and  mouth.  The  eyes  are 
open  and  prominent,  sometimes  showing  subconjunctival  hemorrhages. 
The  surface  of  the  body  is  generally  pale,  occasionally  showing  ]x»ints 
of  ecchymosis  here  and  there.  On  opening  the  body  the  blood  is  found 
dark  and  fluid,  occupying  the  right  side  of  the  heart  and  the  veins. 
The  lungs  are  large,  often  showing  emphysema,  especially  along  the 
anterior  border  and  edges  of  the  base.  They  are  not  so  deeply  engorged 
as  in  some  of  the  other  forms  of  asphyxia,  but  are  usually  reddish  in 
color.  Beneath  the  pericardium,  beneath  the  pleura,  in  the  pia  mater, 
as  well  as  in  the  lungs,  brain,  and  other  viscera,  small  patches  of  hemor- 
rhage, from  the  size  of  a  pin-head  to  fifteen  or  twenty  times  as  large,  are 
very  likely  to  be  found.  These  patches  are  usually  dark  in  color,  round 
in  shape,  and  contrast  strongly  with  the  surrounding  tissue.  There  may 
be  but  few  or  they  may  be  present  in  large  numVjers,  and  sometimes  give 
rise  to  an  almost  granite-like  marking  of  the  lungs.  Infants  are  espe- 
cially likely  to  exhibit  a  large  number  of  such  markings  when  dying 
from  smothering,  and  an  important  situation  for  their  occurrence  in  such 
cases  is  the  thymus  body.  The  mucous  membrane  of  the  respiratory 
passages  is  usually  red  from  congestion,  and  there  is  often  more  or  less 
bloody  froth  accumulated  upon  its  surface.  The  abdominal  organs, 
especially  the  liver,  kidneys,  and  alimentary  walls,  are  congested,  and 
similar  engorgement  is  to  be  noted  in  the  brain.  Exceptions  to  these 
features  may  result  from  great  suddenness  of  death,  usually  because  of 
syncope. 

When  the  victim  has  been  smothered  by  the  application  of  the  hand 
over  the  mouth  and  nostrils,  local  signs  of  violence  in  the  tissues  com- 
pressed are  likely  to  show.     The  nose  is  apt  to  be  compressed ;  the 


SUP'FOCATIOX    FKOM    EXTEHXAL    CAUSES.  233 

cartilage  of  the  septum  is  often  broken  ;  ecchyraoses,  and  occasionally 
subcutaneous  lacerations  alongside  the  nose,  upon  the  cheeks,  and  in  the 
lips  and  gums,  may  be  found.  The  inner  surface  of  the  lips  often  show 
signs  of  injury  fi-om  pressure  on  the  teeth.  There  may  be  more  or  less 
chafing  and  excoriation  of  the  skin  of  these  parts  ;  just  beneath  the 
eyes,  where  usually  the  finger-tips  of  the  nmrderer  are  ap[)lied,  there 
may  be  more  or  less  deep  marks  of  nails.  If  the  chin  has  been  elevated 
forcibly,  or  the  neck  wrenched,  in  the  efforts  at  complete  closure  of  the 
nose  and  mouth,  similar  injuries  may  be  inflicted  to  the  su])niaxillary 
tissues  and  even  dislocation  or  fracture  of  vertebne  occur.  AVlicn  a  cloth 
or  mask  of  some  pliable  substance,  such  as  rubber  or  wax,  is  applied  to 
the  mouth  and  nostrils,  the  local  signs  of  violence  are,  as  a  rule,  much 
less  marked  than  when  the  hand  is  directly  applied  ;  and  it  is  possible, 
if  a  sufficiently  soft,  thick  substance,  as  a  pillow,  is  employed,  that 
there  will  be  absolutely  no  evidence  of  its  contact. 

A  sign  that  should  be  sought  for  in  such  cases,  although  not  gener- 
ally mentioned  in  texts  upon  the  subject,  is  the  existence  of  recent  rup- 
ture of  the  tympanic  membrane.  This  is  not  of  very  rare  occurrence 
in  this  form  of  asphyxia,  taking  place  from  the  violence  of  respira- 
tory effort,  associated  with  the  badly  coordinated  jiharyngeal  and  laryn- 
geal muscular  movements  in  the  period  of  struggle  for  breath. 

In  cases  where  the  individual  has  been  smothered  by  being  purposely 
or  accidentally,  partially  or  completely,  buried  in  sand,  ashes,  mud,  and 
similar  substances,  as  a  rule  the  obstructing  material  will  be  found  in 
the  mouth,  nostrils,  esophagus,  stomach,  or  larynx.  It  is  drawn  into 
the  mouth  and  nostrils  mainly  by  the  struggle  of  the  forced  inspiratorv 
efforts,  and  hence  into  the  larynx  and  trachea.  Its  presence  in  the 
esophagus  and  stomach  is  the  result  of  swallowing  performed  in  order 
to  relieve  the  mouth  of  the  offending  matter.  It  has  been  shown  ex- 
perimentally on  lower  animals  that  the  force  of  such  inspiration  is  suffi- 
cient, holding  the  animal  up  with  head  downward,  in  such  substances  as 
mercury  and  soft  plaster,  to  draw  the  matter  even  into  the  bronchial 
tubes.  Naturally  it  is  impossible  that  any  quantity  of  such  material 
could  find  its  way  into  the  respiratory  and  alimentary  tract  any  distance 
after  life  unless  under  great  pressure.  This  is  even  more  true  than  for 
submersion  in  water,  yet,  practically,  the  mouth  and  nostrils  sometimes 
do  in  some  -way  come  to  contain  at  least  small  amounts,  even  when  the 
body  is  thus  buried  after  death  ;  and  there  are  a  few  cases  on  record 
when,  in  experimental  burial  after  death,  even  the  larynx  has  been  found 
to  contain  small  bits  of  the  surrounding  substance.  It  is,  however,  fair 
to  conclude,  if  such  matter  is  found  in  considerable  amount  and  is 
located  in  the  larvnx  or  lower,  and,  a,s  swallowinti:  is  absolutelv  a  vital 
performance,  in  the  esophagus  or  stomach,  that  the  occlusion  of  the  respira- 
tory openings  occurred  before  death  and  that  smothering  actually  did  take 
place.  When  the  suffocating  mass  is  not  sufficiently  soft  or  light  readily 
to  enter  the  mouth  and  nostrils,  naturally  the  sign  indicated  does  not 
obtain.  It  may  be  possible  to  judge  of  the  completeness  of  obstruction, 
however,  in  such  material  as  mud  by  comparison  of  the  imprint  of  the 


234  DEATH    FROM    ASPHYXIA. 

face  in  the  mud  with  the  features  of  the  corpse.  In  such  cases — as  well 
as  in  any  other  form  of  asphyxiation — particular  care  should  be  taken  to 
exclude  influences  such  as  opium  or  profound  alcoholic  intoxication, 
which  are  capable  of  producing  congestions  and  fluidity  of  the  blood 
postmortem  and  thus  simulate,  more  or  less  closely,  true  asphyxia. 

When  suffocation  has  resulted  from  compression  of  the  chest  and 
abdomen  or  prevention  of  their  respiratory  movements,  examination  will 
usually  reveal  local  injuries  in  these  parts,  either  superficial  or  deep. 
On  June  24,  1824,  in  a  large  crowd  in  the  Champs  de  Mars,  Paris, 
23  persons  thus  met  their  death,  and  for  a  time  were  carried  along  as 
corpses  in  erect  posture  by  the  compact,  singing  mass.  The  degree  of 
compression  may  be  appreciated  when  it  is  stated  that  in  one-tlbird  of 
these  cases  there  were  fractures  of  the  ribs,  and  in  one  case  the  sternum 
was  broken.  These  cases  all  presented  marked  cyanosis  of  the  face  ;  in 
some  cases  there  were  ecchymoses  beneath  the  conjunctivae  and  hem- 
orrhage from  the  nose  and  ears.  On  internal  examination  the  blood 
was  dark,  fluid,  and  especially  collected  in  the  right  heart  and  large 
veins.  The  lungs  were  deeply  congested,  as  were  also  the  abdominal 
viscera  and  the  brain.  In  suffocation  with  less  pressure  upon  the  vic- 
tim's body,  especially  if  the  crowd  is  assembled  in  an  insufficiently  ven- 
tilated space,  there  are  necessarily  absent  such  evidences  of  bodily  injury, 
and,  as  a  rule,  there  is  less  tendency  to  deep  cyanosis  about  the  face  and 
neck  and  internal  and  external  ecchymoses.  In  such  instances  the 
influence  of  carbon  dioxid  and  toxic  exhalations  must  be  recognized. 
Compression  of  the  chest  and  abdomen  by  the  knees  of  a  murderer 
or  other  force  covering  a  comparatively  small  area  is  more  likely  to 
cause  injuries,  as  bruises,  fractures  of  the  sternum  and  ribs,  or  lesions 
of  the  abdominal  viscera,  because  of  the  concentration  of  the  compress- 
ing force  and  the  probability  of  its  suddenness  of  application,  than  where 
the  force  is  widely  distributed,  as  by  the  weight  of  an  overlying  body  or 
the  lateral  pressure  of  a  crowd. 

In  all  forms  of  smothering  the  tendency  to  formation  of  subpleural, 
subpericardial,  and  other  hemorrhages  is  much  less  marked  in  adults 
than  in  infants,  probably  because  of  the  weaker  support  of  the  engorged 
vessels  by  the  surrounding  tissues.  In  searching  for  these  hemorrhagic 
patches  in  infants  the  thymus  body  should  not  be  neglected,  this  appar- 
ently being  a  favorable  situation  for  the  lesion. 

Treatment. — The  provision  of  free,  pure  air,  loosening  of  all  cloth- 
ing, removal  of  every  source  of  compression  and  obstruction  to  the 
passage  of  the  air  to  the  lungs,  artificial  respiration,  and  cardiac  stimu- 
lation constitute  the  main  features  of  treatment.  The  mouth,  nose,  and 
larynx  should  be  examined  if  any  suspicion  is  entertained  of  suffocative 
matter  having  entered  therein.  Venesection  in  the  neck  and  temples, 
friction  of  the  surface,  and  the  application  of  external  heat  may  be 
required  to  aid  in  the  reestablishment  of  circulation.  Of  the  cardiac 
stimulants,  nitroglycerin  is  especially  advantageous.  The  proper  care 
of  local  injuries  should,  moreover,  be  given  as  quickly  as  possible,  when 
they  seriously  complicate  the  major  difficulties.      In  case  of  fractured 


I 


SUFFOCATION    FROM    EXTERXAL   CAUSES.  235 

ribs,  if  the  necessity  for  artificial  respiration  exists,  the  method  of  tongue 
traction  of  Laborde,  ah'cady  mentioned,  is  to  be  preferred. 

Legal  Considerations. — AVhilc,  in  most  cases,  it  is  easy  enough 
from  medical  and  circumstantial  testimony  to  establish  death  from  suiib- 
cation,  cases  necessarily  occur  where,  from  the  insutiiciency  of  one  or 
both,  it  is  quite  impossible  to  declare  absolutely  that  this  was  the  lethal 
cause.  At  best  it  can  be  said  that  such  instiinces  are  compatible  with 
the  suspicion  of  smothering-.  When  the  medical  evidence  includes, 
besides  well-developed  internal  signs  of  asphyxiation  (as  dark  fluid  blood 
in  the  venous  side  of  the  circulation,  congestions  of  the  lungs,  a1)don)inal 
viscera,  and  brain  and  ecchymoses  beneath  the  pleurie,  i)ericardiinn,  and 
dura  mater),  also  well-defined  marks  of  local  injury  about  the  chest  and 
abdomen  or  about  the  mouth  and  nose,  and  more  or  less  facial  cyanosis 
and  ecchymosis,  it  may  be  asserted,  with  reasonable  certainty,  that  the 
victim  was  suffocated.  The  legal  physician  should  have  excluded,  how- 
ever, as  far  as  possible,  such  influences  as  profound  alcoliolic  or  opium 
intoxication.  In  every  case  it  is  unwise  to  rely  with  any  degree  of 
exclusiveness  upon  this  or  that  individual  sign  discovered  ;  and  the  basis 
of  opinion  should  always  be  made  upon  the  entire  group  of  manifesta- 
tions encountered. 

Aside  from  the  evidences  of  violence,  among  the  various  internal 
signs  of  suffocation  the  existence  of  numerous  ecchymoses  is  commonly 
regarded  as  of  the  highest  suggestive  importance.  They  are  the  result 
of  capillary  rupture  in  the  latter  period  of  asphyxiation,  when  the  vas- 
cular pressure  is  at  its  height.  They  are  usually  quite  small,  varying 
in  size  from  that  of  a  common  pinhead  to  that  of  a  buckshot  or  a  little 
larger,  and  are  usually  round  and  well  defined.  A\'hile  most  frequent 
in  the  subpleural  and  subpericardial  tissues  of  the  adult  and  in  the 
thymus  body  of  the  child,  they  may  have  a  very  wide-spread  occurrence 
and  may  be  found  in  the  peritoneum,  abdominal  viscera,  brain,  conjunc- 
tiva and  retina,  tympanum,  mucous  membrane  of  the  mouth  and  respira- 
tory passages,  and  on  skin,  especially  of  the  face.  These  ecchymoses  may 
occur  in  any  form  of  mechanical  asphyxiation,  but  are  most  frequently 
and  uniformly  met  in  cases  of  death  bv  smothering.  Care  should  be 
taken  to  exclude  the  possible  agency  of  various  hemolytic  diseases  and 
poisons  and  the  mechanical  effects  of  different  forms  of  cardiac  diseases 
in  the  production  of  such  suggillations. 

Should  there  be  reason  to  suspect  that  suffocation  has  resulted  from 
occlusion  of  the  mouth  and  nose  bv  one  or  other  means,  the  discovery 
of  recent  tympanic  rupture  should  be  regarded  as  of  decided  confirma- 
tory value. 

The  value  of  evidences  of  injury,  found  upon  the  surface  or  in  the 
structures  underlying  the  applied  force,  about  the  mouth  or  in  the 
thoracic  wall  is  unquestioned  ;  but  the  possibility  of  infliction  of  such 
injuries  without  actual  destruction  of  life  is  also  indubitable,  and  they 
are,  therefore,  to  be  accejited  only  in  connection  with  the  other  evi- 
dences of  smothering.  So,  also,  with  reference  to  the  presence  of  some 
obstructing  matter  in  the  mouth  and  nose,  identical  with  that  on  the 


236  DEATH    FROM    ASPHYXIA. 

exterior  of  these  openings  ;  while  it  must  be  strongly  suggestive  that  the 
individual  came  to  his  death  by  smothering,  for  example,  if  a  body  is 
found  partially  or  completely  buried  in  mud  or  ashes  and  portions  of 
such  substances  are  discovered  in  the  situations  named ;  yet  it  must 
never  be  forgotten  that  it  is  possible,  if  the  body  is  placed  in  similar 
conditions  after  death,  that  penetration  of  the  open  mouth  and  nostrils 
bv  the  semifluid  or  pulverulent  matter  might  occur  to  some  degree. 
The  depth  of  the  penetration  and  the  amount  of  material  should  indicate 
here  the  probability  ;  and  in  case  the  material  in  question  has  been 
found  in  the  esophagus  or  below  the  glottis,  there  can  be  very  little 
question  as  to  the  reality  of  death  by  smothering. 

In  fact,  it  is  generally  assumed  that  proof  is  complete  in  such  in- 
stances, particularly  when  the  substance  is  found  in  the  esophagus,  as 
this  would  indicate  the  vitality  of  the  victim  when  brought  in  contact 
with  the  matter  swallowed.  This  feature  may  be  insisted  upon  in  such 
cases  where  it  is  declared  in  defense  that  the  body,  already  dead  from 
other,  perhaps  natural,  cause,  was,  for  some  comparatively  innocent 
motive,  placed  in  such  material  ;  and  the  presence  of  the  foreign  matter 
in  the  esophagus  may  be  regarded  as  surely  demonstrating  that  life  was 
not  extinct  when  the  body  was  thus  disposed  of.  Of  course,  it  in  nowise 
excludes  other  influences  of  which  there  may  be  evidence  contributory 
to  death. 

In  fixing  the  responsibility,  the  question  of  suicide,  although  possi- 
ble, practically  never  arises.  Except  in  infants  and  adults  disabled 
from  some  cause,  prima  fade  inference  is  properly  homicidal,  and  this 
should  be  maintained  unless  opposed  by  collateral  testimony.  In  both 
these  excepted  groups,  moreover,  smothering  is  not  an  infrequent  mode 
of  homicide.  The  existence  of  distinct  signs  of  violence  of  a  character 
suggesting  suffocating  force  is  to  be  interpreted  as  indicating  murder, 
unless  reasonably  referable  to  accident ;  but  the  absence  of  such  signs 
does  not  preclude  action  for  murder.  The  responsibility  for  the  frequent 
death  of  infants  from  "  overlying  "  is  difficult  to  decide  ;  but  death 
from  such  cause  can  often  be  shown  to  be  due,  at  least,  to  contributory 
negligence  on  the  part  of  the  caretaker.  It  is  true  that  occasionally 
infants  are  born  dead  with  fairly  marked  subpleural  ecchymoses  and 
fluid  blood  characteristic  of  suffocation ;  it  is  necessary,  therefore, 
before  assertina:,  in  cases  of  vouncr  infants  found  dead  with  these  signs 
shown  upon  autopsy,  that  legal  suffocation  had  taken  place,  to  establish, 
by  observation  of  the  size  and  appearance  of  the  lungs  and  by  floating 
a  portion  of  pulmonary  tissue  upon  water,  that  respiration  had  taken 
place  before  death  and  that  the  lungs  had  been  inflated  by  air. 

Confinement  in  coffins  and  entombment  before  death  occasionally 
do  occur,  and  suffocation  from  inclosure  may  cause  or  contribute  to  the 
cause  of  death.  This  is,  however,  practically  impossible  when  proper 
inspection  of  the  body  has  been  made  by  a  qualified  person,  and  legal 
responsibility  is  thereby  transferred  to  the  inspecting  physician  or  other 
officer.  While  exceedingly  rare,  the  mere  possibility  should  urge  the 
advisability  of  such  inspection.     When,  on  the  other  hand,  a  body  is 


SUFFOCATION    FROM    CAUSES    OPERATIXCi    INTERNALLY.  237 

found  buried  in  an  ash-barrel,  privy  vault,  or  other  situation  of  simi- 
larly improper  type,  as  is  often  the  case  with  the  bodies  of  the  newly 
born,  and  presenting  evidences  of  probable  suifocative  death,  the  re- 
sponsibility for  crime  may  be  reasonably  attached  to  whatever  person 
may  be  shown  to  have  thus  disposed  of  the  body,  unless  distinct  evi- 
dence for  his  relief  can  be  presented. 

(b)  Suflfocation  from  Causes  Operating  Internally. — In  a 
general  sense  all  lesions  impairing  the  receptive  })()wer  of  the  lungs 
which  may  arise  within  the  body,  as  well  as  the  conditions  preventing 
proper  hematosis  and  convection  of  the  arterialized  blood  to  the  tissues 
and  its  return  to  the  lungs  after  performance  of  its  function,  should  be 
included  in  such  a  category.  Acute  pneumonia,  pulmonary  edema, 
tuberculous  and  other  destructions  of  lung  tissue,  fibrosis  of  the  lungs, 
and  the  various  anemias,  as  well  as  various  circulatory  diseases,  might 
properly  be  classified  here  ;  but  in  that  they  possess  no  medicolegal  interest 
save  as  natural  forms  of  disease,  they  cannot  here  receive  attention,  and 
consideration  is  limited  to  the  results  of  inhalation  of  certain  irases 
which,  by  blood  alteration,  are  capable  of  interfering  with  the  respira- 
tory function.  As  alreadv  indicated,  these  should  rather  be  regarded  as 
intoxicants,  and  may,  under  special  conditions,  possess  other  and  more 
rapidly  fatal  influences  than  that  of  blood  destruction.  Here  may  be 
included  such  agents  as  carbon  monoxid,  sulphureted  hydrogen,  arsenu- 
reted  hydrogen,  hydrocyanic  acid,  chlorin,  nitrous  vapors,  as  well  as 
some  of  the  anesthetic  vapors.  The  last  important  group  is  elsewhere 
separately  considered  in  this  work. 

1.  Carbon  monoxid  (CO),^  carbouous  oxid,  also  improperly  known 
as  carbonic  oxid,  is  a  product  of  incomplete  oxidation  of  carbonaceous 
matter.  It  is  a  colorless,  odorless  gas,  lighter  than  air.  It  is  combusti- 
ble, burning  with  a  pale-blue  flame  and  producing  carbonic  acid  gas,  but 
it  does  not  sustain  combustion.  This  gas  is  produced  in  large  quantities 
in  the  combustion  of  ordinary  inflammable  matter  unprovided  with  free 
access  of  air  ;  it  does  not  develop  in  nature  in  any  important  amount. 
It  arises  from  lime-kilns,  brick-kilns,  charcoal-kilns,  from  conflagrations 
without  free  sup})ly  of  air,  as  in  the  interior  of  buildings,  where  it  plays 
a  most  important  part  in  cases  of  sufl'ocation  from  smoke,  from  common 
charcoal  and  coke  furnaces,  from  coal  furnaces,  and  ordinary  stoves  when 
an  insufficient  supply  of  air  is  provided.  After  first  lighting  a  coal-fire, 
and  again  when  the  incandescent  coals,  as  the  fire  burns  low,  become 
smothered  in  ashes,  this  gas  is  formed  in  marked  excess  over  the  dioxid 
of  carbon,  and  can  often  be  seen  burning  with  a  light-blue  flame  over  the 
surface  of  the  mass.  When  the  whole  mass  is  well  aflame,  with  a  fiiir 
draught,  however,  the  carbon  is  more  completely  oxidized  and  the  pro- 
portion of  CO  is  much  less  than  at  the  beginning  and  end  of  the  process. 
Again,  if,  on  accomit  of  insufficient  opening  for  entrance  of  air  at  the 
bottom  of  the  stove,  or  on  account  of  the  small  amount  of  available 
oxygen  in  the  small  and  badly  ventilated  room,  the  fire  should  burn  but 
slowly,  this  underoxidized  carbonic  gas  is  formed  in  large  amount.  Any 
imperfection  of  the  stove-pipe  or  of  the  flue  by  which  its  escape  into 
*  Consult  also  the  chapter  on  "  Gaseous  Poisons"  in  Vol   II.  of  this  work. 


238  DEATH    FROM    ASPHYXIA. 

the  room  is  possible,  or  by  which  its  free  passage  to  the  exterior  is  im- 
peded, must  favor  its  collection  in  dangerous  relation  to  the  inhabitants 
of  the  apartment.  In  a  small,  ill-ventilated  room,  when  the  consump- 
tion of  the  air  of  the  room  by  the  fire  has  caused  relative  rarefaction, 
one  can  readily  perceive  how  the  deleterious  product  of  the  partial 
oxidation  consequent  upon  small  air-supply  should  pass  from  the  stove 
out  into  the  atmosphere  of  the  apartment.  The  size  and  ventilation 
of  the  room  enter  as  important  factors  only  in  this  latter  relation,  the 
proportion  of  the  gas  to  the  other  elements  of  the  atmosphere  having 
little  or  no  consequence.  Only  that  portion  of  the  gas  in  a  room  which 
enters  into  the  blood  has  any  eifect,  and  if  long  enough  time  is  given  to 
the  exposure,  a  small  percentage  will  acconq)lish  as  much  harm  as  a 
larger  proportion  in  less  time.  In  fact  it  is  quite  possible  that  the 
results  may  follow  if  the  gas  is  inhaled  in  the  open  air  and  with  it. 
In  this  feature  it  differs  from  the  dioxid,  which  is  mainly  mechanical 
in  its  action,  merely  excluding  a  certain  amount  of  respirable  air,  and 
requires  a  certain  degree  of  proportionate  accumulation  before  its  effects 
can  be  produced.  Finally,  this  gas  is  an  imjiortant  constituent  of  illu- 
minating gas,  especially  that  known  as  "  w^ater-gas,"  and  is  largely 
responsible  for  the  fatal  effects  of  its  inhalation. 

Suffocation  by  carbon  monoxid  has  long  been  a  favorite  mode  of 
self-destruction,  and  occasionally  of  homicide  in  certain  countries,  par- 
ticularly in  the  district  of  the  Seine  in  France.  The  victim  usually 
shuts  himself  closely  in  a  small  room  with  a  lighted  brazier  of  charcoal, 
and  becomes  overcome  by  the  gas  arising  therefrom,  gradually  and 
without  particular  discomfort.  In  1891  the  statistics  show  that  in 
France  as  many  as  848  suicides  by  this  method  occurred,  nearly  one- 
fifth  of  all  the  suicides  of  the  republic  for  that  year ;  and  an  enormous 
and  steady  increase  is  shown  in  each  decade  of  the  century.  This  fre- 
quency of  suicide  in  France  is  doubtless  entirely  explicable  upon  the 
popular  use  of  charcoal  and  coke  furnaces  for  cooking,  the  ease  and 
readiness  with  which  the  means  of  suicide  can  therefore  be  obtained, 
and  the  poj)ular  knowledge  of  the  painlessness  of  the  process.  In  our 
country  and  England  suicide  by  this  method  is  practically  unknown, 
and  deaths  from  its  influence  are  almost  invariably  accidental.  Tramps, 
attracted  by  the  warmth  about  the  top  of  a  lime-kiln,  lie  down  close  to 
the  opening  or  on  a  board  over  it,  and  arc  overcome  by  the  gas  emanat- 
iupf  from  the  combustion  below.  Suffocations  occur  from  the  entrance  of 
the  gas  from  a  coal-fire  in  some  way  into  the  air  of  a  room,  and  gradu- 
ally the  inhabitants,  ignorant  of  their  danger,  are  overcome.  Ignorant 
or  careless  failure  properly  to  turn  off  the  stream  of  illuminating  gas 
after  extinguishing  the  light  in  some  improper  manner,  as  by  blowing 
it  out,  often  terminates  the  imprudent  person's  life  in  an  hour  or  two. 
The  noxious  effects  of  this  gas  depend  upon  the  fact  that  after  inhala- 
tion it  forms  rapidly,  with  the  hemoglobin  of  the  red  blood-cells,  a 
combination  more  stable  than  that  resulting  from  the  union  of  oxygen 
with  this  coloring-matter  in  the  ordinary  process(ts  of  respiration.  The 
material  thus  formed,  known  as  carbon  oxyhemoglobin  or  carbon  oxid 


SUFFOCATION    FROM    CAUSES    OPERATING    INTERNALLY.  239 

hemoglobin,  being  practically  incapable  of  oxygen  absorption,  and  the 
blood  plasma  likewise  being  unable,  from  greater  or  less  occupation  by 
the  gas,  to  take  in  the  respiratory  oxygen,  the  process  of  hematosis  is 
impossible  and  asjihyxia  results. 

Symptoms. — The  manifestations  of  intoxication  by  this  gas  depend 
much  upon  the  rapidity  of  the  process.  A  massive,  gradual  or  chronic, 
form  of  intoxication  may  be  ])resent.  The  first  type  occurs  occasionally 
on  entrance  into  an  atmosphere  of  ordinary  illuminating  gas,  which  con- 
tains from  4  to  30  per  cent,  of  this  gas,  according  to  its  kind,  or  into 
an  atmosphere  surcharged  with  carbon  monoxid.  The  victim  falls  as 
if  struck,  and  is  dead  within  a  few  minutes,  apparently  from  immediate 
exclusion  of  oxygen  and  before  complete  conversion  of  the  hemoglobin 
into  carbon  oxid  hemoglobin.  There  may  be  some  specific  action  exerted 
by  the  gas  also,  but  this  is  uncertain,  and  the  process  closely  resembles  the 
rapid  asphyxiation  by  carbon  dioxid.  Convulsions  are  not  infrequently 
present. 

By  far  the  most  important  train  of  events,  from  a  legal  point  of  view, 
occurs  in  the  gradual  asphyxiation  resulting  from  more  or  less  prolonged 
respiration  in  an  atmosphere  containing  a  relatively  small  proportion  of 
the  gas  in  question.  The  actual  amount  of  gas  in  the  air,  and  even  the 
proportionate  amount,  is  of  little  moment,  and  should  not  be  insisted 
upon  in  any  case,  provided  the  time  during  which  the  gas  was  respired 
has  been  sufficiently  prolonged.  In  other  words,  tlie  results,  depend  in 
this  form  rather  upon  the  amount  of  carbon  monoxid  entering  the  blood, 
both  hemoglobin  and  plasma,  than  that  present  in  the  air.  This  mini- 
mum fatal  dosage  can  ])e  determined  only  Avith  the  greatest  difficidty, 
and  then  only  approximately  at  best ;  but  for  an  average  human  being 
it  is  probably  within  one  or  two  grams. 

The  futility  of  quantitative  estimation  of  the  gas  in  any  atmosphere 
in  which  death  has  occurred  can  be  the  more  readily  understood  when 
one  recalls  that  one  may  be  killed  in  open  air,  where  the  percentage  of 
gas  is  likely  to  be  constantly  varying,  if  close  to  its  source,  and  that 
even  in  an  inclosed  room,  where  the  gas  is  accumulating  from  a  stove 
or  furnace,  it  may  continue  to  increase  after  the  inhabitant  has  been 
destroyed.  The  proportions,  as  commonly  given,  are  not  only  subject 
to  such  objections,  but  are  quite  too  high.  Briande  and  Chaude,  in 
their  work  on  Legal  Medicine,  name  as  a  lethal  proportion  4  or  5  per 
cent.,  based  upon  certain  experiments  of  Leblanc  upon  dogs  killed  by 
this  gas  in  projiortion  of  5  to  1000.  Experiments  have  shown,  however, 
that  dogs  exposed  for  a  long  time — several  days — are  killed  when  a 
much  smaller  proportion  exists — 1  to  7000 — in  the  atmosphere.  This 
much  can  be  said,  however,  that  4  or  5  per  cent.,  and  in  isolated  cases 
a  smaller  amount,  of  carbon  monoxid  in  the  atmosphere  may  prove 
rapidly  flital,  but  that  much  smaller  pro])ortions  may,  if  continuously 
inhaled  for  a  long  jieriod,  also  prove  fatal,  and  tliat  the  absolute  amount 
necessary  to  kill  cannot  be  stated. 

Individuals  thus  exposed  to  the  gradual  poisoning  eiFects  of  car- 
bonous  oxid  include  the  vast  bidk  of  those  brought  to  the  attention  of 


240  DEATH    FROM    ASPHYXIA. 

the  legal  physician  dead  from  this  gas  ;  suicides  from  the  use  of  char- 
coal furnace  ;  imprudent  and  ignorant  people  accidentally  killed  by  the 
fumes  from  badly  ventilated  stoves  and  furnaces ;  from  kilns  and  by 
illuminating  gas  of  one  or  other  type  esca])ing  into  the  apartment.  The 
course  of  such  a  case  is  quite  variable — from  a  half-hour  or  an  hour  to 
several  days.  For  a  time  the  victim  feels  an  intense  pain  and  pressure 
in  the  temporal  regions' ;  there  is  likely  to  be  more  or  less  tinnitus 
aurium,  and  sometimes  there  are  ocular  disturbances.  He  feels  dizzy. 
There  may  be  hallucinations  or  illusions.  During  this  period  of  some 
minutes  or  an  hour  there  is  no  especial  difficulty  of  escape  if  such  is 
desired  and  the  danger  realized.  Presently,  however,  the  effects  of 
intoxication  become  more  marked ;  the  muscular  power  becomes  ])ro- 
gressively  weaker  until  the  victim  is  helpless.  Nausea  and  vomiting 
are  commonly  present;  sometimes  there  is  general  sphincter  relaxa- 
tion. Mentality  gradually  becomes  dulled,  and  a  decided  tendency  to 
sleep  develops.  The  pulse  at  first  is  scarcely  disturbed ;  it  gradually 
increases  in  force  and  rapidity  during  the  first  period,  but  with  the 
oncome  of  the  symptoms  of  weakness  soon  loses  its  strength  and  becomes 
more  or  less  intermittent. 

The  respirations,  at  first  but  little  disturbed,  become  rapid,  shallow^, 
and  often  stertorous.  Somnolence  gradually  passes  into  coma.  The 
respiratory  and  circulatory  functions  become  more  and  more  insuffi- 
cient, and  finally  the  unhappy  one  dies.  This  last — comatose — period 
is  likely  to  be  longer  in  duration  than  either  of  the  preceding  ones.  It 
lasts  sometimes  several  days  before  death.  It  is  possible,  even  after 
coma  has  been  present  for  a  considerable  time,  to  resuscitate  the  patient. 
Should  attempts  at  resuscitation  be  successful,  the  individual  is  generally 
for  a  long  time  more  or  less  anemic,  weak,  and  mentally  dull  or  dis- 
turbed. Palsies  of  greater  or  less  degree  and  of  varying  distribution 
have  been  encountered.  Peripheral  gangrene,  pemphigus,  herpes  zoster, 
and  disturbances  of  the  special  or  general  sensibility  are  recorded. 

The  chronic  effects  of  carbonous  oxid  intoxication  more  frequently 
engage  the  attention  of  the  general  practitioner  than  of  the  legal  phy- 
sician. They  occur  in  persons  exposed  more  or  less  continuously  to 
mmute  amounts  of  the  gas,  as  those  constantly  immuring  themselves  in 
houses  into  which,  on  account  of  faulty  gas-fittings,  illuminating  gas  in 
small  amounts  gains  access,  or  those  whose  occupations  keep  them  more 
or  less  continuously  in  an  atmosphere  somewhat  contaminated  by  the 
gas,  as  the  workers  about  kilns,  iron  foundries,  and  gas  manufactories. 
Bakers,  launderers,  and  cooks,  who  are  for  much  of  their  time  about 
red-hot  ovens  and  stoves,  through  whose  heated  iron  walls  small  quan- 
tities of  CO2  are  apt  to  pass  and  in  jiassage  give  up  a  part  of  tlieir 
oxygen,  are  likewise  subject  to  this  variety  of  intoxication.  The  most 
constant  and  important  symptom  of  this  variety  is  the  progressive  type 
of  anemia  resulting  from  the  gradual  destruction  of  the  blood  and  the 
wide-spread  secondary  symptoms  of  this  state.  Brouardel  calls  atten- 
tion to  occasional  cholera-like  attacks  which  are  often  met,  especially  in 
the  last-named  group,  which,  at  least  in  part,  he  attributes  to  carbon- 


SUFFOCATION    FROM    CAUSES    OPERATING    INTERNALLY.  241 

monoxid  poisoning.  Experiments  of  Hava  would  indicate  that  in  this 
form,  where  the  process  has  been  continued  for  months  or  years,  the 
hemoglobin  formation  going  on  with  sutKcient  activity  to  make  life  pos- 
sible, this  substance  may  accumulate  in  the  ditfused  hemoglobin  of  the 
muscles  to  such  an  extent  as  to  make  the  mass  inflammable  in  a  condi- 
tion which  would  explain  instances  of  so-called  "  spontaneous  combus- 
tion "  if  the  element  of  spontaneity  be  eliminated. 

Treatment. — \\  hile  it  is  true  that  carbon  oxid  hemoglobin  is  more 
stable  than  oxyhemoglobin,  and  that  ordinarily  the  blood  of  one  thus 
poisoned  fails  to  take  up  oxygen  and  become  arterialized,  nevertheless  it 
is  also  true  that  in  the  presence  of  oxygen  the  carbonous  oxid  is  gradu- 
allv  raised  to  the  higher  oxid,  which  is  capable  of  disengagement  from 
the  blood.  Free  iniialation  of  oxygen,  if  necessary  by  forced  respira- 
tion, should  therefore  be  practised  whenever  possible  ;  and  at  least  in  all 
cases  artificial  respiration  should  ])e  insisted  upon  as  a  valuable  measure. 
Venesection  and  replacement  of  the  removed  by  directly  transfused 
blood  offers  theoretically  an  ideal  mode  of  dealing  with  the  condition, 
unfortunately  rarely  available.  ^lere  withdrawal  of  blood,  unless  indi- 
cated by  existing  engorgements  of  the  venous  circulation,  is  not  advisa- 
ble, since  it  lowers  still  further  the  already  diminished  oxygen-bearing 
power  of  the  blood.  Circulatory  stimulation  is  demanded  in  nearly  all 
cases,  and  hypodermic  administration  of  rapidly  dittusible  stimulants,  as 
ether  and  nitroglycerin,  are  often  of  decided  value.  When  conscious- 
ness has  returned,  attention  should  \)e  given  to  the  lungs  and  respiratory 
mucous  membrane,  and  the  possibility  of  development  of  an  inspiration 
pneumonia  by  the  entrance  of  particles  of  the  vomitus  into  the  respira- 
tory passages,  as  well  as  of  bronchitis  and  tracheitis  from  the  irritation 
by  the  gases  or  soot  particles  arising  from  combustion,  be  recognized. 
The  various  subsequent  results,  as  the  anemia  and  its  consequences,  are 
to  be  counteracted  by  careful  and  full  nourishment  and  hygienic  caution, 
as  well  as  by  medicaments  indicated  from  time  to  time. 

Postmortem  Appearances. — While  fairly  constant,  the  postmortem 
appearances  are  suljject  to  some  variation,  and  these  apparently  depend 
largely  upon  the  rapidity  of  the  process  and  length  of  time  after  death 
when  the  autopsy  is  performed.  There  are,  however,  so  many  special 
conditions  of  environment  and  so  many  other  agencies  possible  in  co- 
operation Avith  the  carbonous  oxid  that  it  is  not  surprising  that  indi- 
vidual cases  do  not  adhere  to  the  usual  rules.  As  a  general  thing  the 
lips  and  face,  as  well  as  a  greater  or  less  part  of  the  surface  of  the  body, 
are  of  a  life-like,  rosy  tint.  But  there  are  cases  in  which  the  face  is 
pallid  and  all  the  surfaces  except  dependent  ])arts  at  least  blanched. 
These  are  usually  those  dead  in  a  few  moments  from  massive  action  of 
the  poison,  which  are  analogous  to  the  syncopal  deaths  from  other  asjihyx- 
iating  influences.  Others,  again,  remind  one  of  the  eflects  of  choking 
from  the  dioxid  with  SAVollen  cyanotic  faces  and  necks  ;  and  these  also 
generally  occur  among  the  instances  of  massive  intoxication.  The  rosy 
tint  of  the  body  surface  is  usnallv  not  uniformlv  distributed,  but  is  best 
seen  in  large  patches  over  the  abdomen,  thighs,  chest,  and  in  the  depen- 

VoL.  I.— 16 


242  DEATH    FROM    ASPHYXIA. 

dent  parts,  where  it  may  be  more  or  less  masked  by  ordinary  postmor- 
tem hypostasis  and  lividity.  The  features  are  usually  composed,  the 
mouth  partly  open,  the  eyes  open,  and  bright  as  in  life.  It  is  said  that 
body-heat  and  postmortem  rigidity  are  of  exceptionally  long  duration. 
On  section,  the  most  marked  and  invariable  sign  is  the  bright,  cherry- 
red  color  of  the  blood,  which  is  quite  fluid  and  flows  from  even 
slight  cuts.  Ordinarily  this  character  is  maintained  by  the  blood 
throughout  the  body,  but  in  a  number  of  cases,  and  these  usually  those 
dying  rapidly,  just  as  from  carbonic  acid  choking,  in  which,  particularly 
in  some  parts  of  the  body,  as  in  the  abdominal  veins,  the  blood  is  almost 
black  and  thick.  It  is  probable  that  these  persons  die  too  quickly  to 
permit  the  action  of  the  carbonous  oxid  upon  the  entire  volume  of  blood. 
The  idea  of  the  cooperation  of  the  dioxid  also  in  the  atmosphere,  along 
with  the  monoxid,  and  its  selective  action  on  the  blood  of  these  parts, 
is  scarcely  credible. 

The  peculiar  appearance  of  the  blood  is  perhaps  the  most  character- 
istic sign  of  carbon  monoxid  poisoning,  and  should  always  lead  to  spectro- 
scopic and  chemical  tests  for  verification  and  separation  from  the  some- 
what similar  appearance  due  to  other  poisons,  as  cyanogen  or  its  deriva- 
tives. The  blood  does  not  readily  decompose  and,  if  placed  in  a  clean 
test-tube  or  vial  and  well  stoppered,  it  may  be  kept  for  weeks  or  months 
in  excellent  condition  for  exact  examination.  Spectroscopically  this  blood 
gives  rise  to  tw^o  bands,  very  like  those  of  oxyhemoglobin,  but  narrower 
and  beginning  a  little  further  to  the  right.  Like  the  absorption  liands 
of  oxyhemoglobin,  l)oth  these  bands  lie  between  the  Fraunhofer  lines 
D  and  E,  but  do  not  touch  them  ;  the  A  band  is  a  little  narrower  and 
darker  than  the  B  band.  A  further  difference  between  the  spectrum  of 
carbon  oxid  hemoglobin  and  oxyhemoglobin  is  this  :  While  the  addi- 
tion of  a  reducing  agent,  as  a  drop  or  two  of  ammonium  sulphid  solu- 
tion, to  the  blood  will  cause,  in  the  latter,  the  two  bands  to  merge  into 
one  broad  band,  the  same  efibrt  will  fail  to  modify  the  absorption  bands 
of  carbon  oxyhemoglobin.  A  chemical  test  of  simplicity,  showing  this 
particular  change  in  the  blood,  may  be  performed,  according  to  Kata- 
yama,  as  follows  :  Acetic  acid  and  ammonium  sulphid,  with  sulphur  in 
solution,  are  added  to  the  blood  to  ))e  tested,  when  a  clear  rose-red  color 
is  produced  ;  with  normal  blood  a  greenish-gray,  sometimes  with  a  slight 
red  tint  added,  is  produced.  The  blood  is  mainly  found  in  the  venous 
side  of  the  circulation,  but  may  be  met  in  both  sides  of  the  heart  and 
in  the  arteries  as  well  as  veins.  In  case  of  spectroscopic  examination 
of  the  dark  blood  occasionally  found,  the  peculiarity  of  the  carbon  oxid 
hemoglobin  spectrum  is  maintained. 

The  heart  presents  no  especial  features  of  interest;  it  is  usually 
found  in  a  relaxed  state.  The  lungs  are  somewhat  congested,  rather 
large,  and  of  a  brick-red  color,  best  seen  on  section.  They  are  likely 
to  be  somewhat  edematous.  The  mucous  membrane  of  the  respiratory 
tract  is  g-enerally  bridit  red  in  color,  but  without  much  exudate,  and  is  free 
from  froth.  Hemorrhages  are  not  common,  but  subpleural  spots  simdar 
to  those  seen   in  cases  of  mechanical   suifocation   are  sometimes  found. 


( 


SUFFOCATION  FROM  CAUSES  OPERATING  INTERNAL,LY.    243 

The  abdominal  organs  are  usually  red  and  congested.  The  redness  and 
j)()ssiI)lo  presence  of  hemorrhagic  spots  may  suggest  the  existence  of  an 
acute  inflainmatory  process  in  tlie  gastric  and  enteric  mucous  membrane, 
as  from  an  irritant  poison,  wliich  might  mislead.  The  gastric  and  in- 
testinal digestion  is  checked  by  this  poison,  and  the  degree  of  digestion 
of  food  in  the  stomach  may  afford  some  suggestion  as  to  the  time  when 
the  intoxication  took  place.  Putrefaction  is  delayed,  but  not  entirely, 
and  after  a  time  the  dcvelo]mient  of  intestinal  gases  causes  sufficient 
pressure  to  force  more  and  more  red  blood  to  the  surface  and  thus  extend 
the  ruddy  areas  described.  The  brain  is  usually  somewhat  congested 
and  ])inkish  in  color.  As  already  suggested,  this  gas  is  believed  to  be 
an  important  factor  in  destroying  life  in  persons  in  buildings  burning  in 
the  interior  without  free  ingress  of  oxygen  ;  many  instanc{>s  occurring 
where  jiersons  are  found  dead  untouched  by  flame  or  heat  and  even  with 
little  evidence  of  having  inhaled  much  smoke.  Death  is  usually  said 
to  have  been  due  to  inhalation  of  smoke  ;  but  probably  this  gas  and 
perhaps  CO^  are  the  important  factors  to  be  considered. 

In  the  Ixxlies  of  those  suffocated  by  the  smoke  of  conflagrations,  in 
addition  to  the  above  general  features,  the  presence  of  particles  of  soot 
all  along  the  respiratory  tract  should  be  noted.  When  these  bodies  are 
also  exposed  to  the  heat  of  the  fire  or  direct  flame,  aside  from  the  crack- 
ing of  the  skin  and  the  baking  and  charring  of  the  skin  and  flesh,  small 
vermicular  coagula,  ])ointed  out  by  Brouardel,  are  to  l)e  found  in  the 
vessels,  especially  in  the  lungs.  These  are  due  to  the  cooking  of  the 
hemic  all)umins. 

Legal  Considerations. — The  determination  of  the  actual  cause  of 
death  by  carbon  monoxid  is  a  matter  of  comparatively  little  difficulty 
on  account  of  the  well-marked  signs  found  in  most  patients  who  have  thus 
perished,  and  by  the  spectroscopic  and  chemical  examination  of  the  blood. 
It  is  a  frequent  thing,  after  a  nnu'der,  for  the  house  containing  the  dead 
body  to  be  set  on  lire  by  the  murderer  in  order  to  conceal  the  crime  by 
entire  destruction  of  the  corpse  or  by  creating  a  belief  that  the  victim  was 
suffocated  accidentally.  Careful  examination  of  the  respiratory  passages 
and  blood  of  the  dead  :hould  be  at  once  made,  and  in  the  absence  of 
the  characters  described,  it  may  be  stated  with  certainty  that  this  latter 
suspicion  is  groundless  and  that  death  took  place  from  cause  other  than 
suffocation  by  the  smoke. 

Tlie  determination  of  the  question  whether  death  was  homicidal,  sui- 
cidal, or  accidental,  must  rest  almost  solely  u])on  collateral  evidence.  It 
is  comparatively  rare,  however,  that  such  deaths  in  tin's  country  are  other 
than  accidental,  the  residt  of  ignorance  or  imprudence,  while  homicides 
are  practically  unknown  among  us  by  such  means.  Abroad,  however, 
in  France  a  few  homicidal  instances  are  upon  record.  Brouardel  sug- 
gests that  in  cases  of  suspicion  strong  circumstantial  evidence  of  com- 
plicitv  mic^ht  be  obtained  bv  discovery  of  CO  in  the  blood  of  the 
suspected  person,  the  characteristic  tests  for  which  may  be  obtained  a 
number  of  days  after  inhalation  if  a  considerable  amount  had  been 
inspired. 


244  DEATH    FROM    ASPHYXIA. 

Questions  involving  the  order  of  death  have  caused  mvestigation  as 
to  the  relative  resistive  power  of  males  and  females,  of  the  adult  and 
young,  and  as  to  the  most  fatal  level  in  a  contaminated  atmosphere 
(raised,  as  upon  a  bed,  or  upon  the  floor).  No  constant  rule  may  be 
stated  ;  the  best  that  can  be  said  is  that  usually  males  succumb  more 
quickly  than  females  ;  that  with  more  regularity  children  die  earlier  than 
adults,  and  that  on  account  of  the  ready  diffusion  of  the  gases  of  com- 
bustion with  the  atmosphere  of  a  closed  room  and  with  each  other,  posi- 
tion, elevated  or  low,  has  little  or  no  influence  upon  the  rapidity  of 
poisoning.  Precise  answers  to  the  proportionate  amount  of  CO  in 
the  atmosphere  upon  the  discovery  of  the  body,  or  the  amount  of 
charcoal  or  other  fuel  required  to  produce  a  lethal  amount  or  proportion 
of  the  gas,  are  of  little  value,  as  already  pointed  out,  unless  due  atten- 
tion is  also  paid  to  the  probable  duration  of  exposure,  character  of  fuel 
and  ash,  form  of  stove  or  furnace,  provision  for  ventilation,  and  other 
similar  questions.  Even  then  the  sources  of  error  possible  are  so  great 
and  the  mformation  so  indefinite  in  its  real  import  except  where  large 
proportions  of  the  gas  are  found,  that  such  features  must  remain  only 
secondary. 

Sulphureted  hydrogen  (HgS)  acts  similarly  to  carbon  monoxid  by 
forming  a  relatively  even  more  stable  compound  with  the  hemoglobin 
of  the  blood  and  thus  producing  asphyxia  by  interference  with  hema- 
tosis.  Its  most  characteristic  change  is  produced  on  the  blood,  to  which 
a  dirty  greenish  tint  is  given.  The  gas  may  be  determined  spectroscoj)- 
ically  and  chemically,  but  a  very  important  source  of  error  arises  from 
the  possibility  of  generation  of  gas  in  putrefaction  to  cast  an  immov- 
able doubt  upon  the  results  of  estimation.  It  is  met  especially  in  the 
gas  of  privy  vaults  and  in  certain  manufacturing  processes  and  about 
sulphur  springs,  and  possesses  dangerously  noxious  powers. 

Arsenureted  hydrogen  (AsHg),  a  gas  occasionally  accidentally  in- 
haled in  chemical  laboratories,  as  in  connection  with  the  Marsh  test  in 
cases  of  arsenical  poisoning,  possesses  dangerously  poisonous  properties. 
Its  fatal  consequences  depend  upon  hemic  destruction,  apparently  by 
changing  hemoglobin  into  methemoglobin. 

The  symptoms  of  poisoning  may  be  immediate  or  postponed  for  some 
hours,  and  are  those  of  ordinary  arsenic  poisoning.  Its  course  is  usually 
more  protracted,  and  may  last  a  week  or  more.  Besides  the  destruction 
of  the  blood-cells  and  production  of  anemia,  it  produces  as  a  fairly  con- 
stant lesion  more  or  less  well-marked  fatty  degeneration  of  various 
structures,  and  causes  hemorrhages  of  varying  severity. 


DEATH  AND  INJURIES  BY  LIGHTNING  AND 

ELECTRICITY. 


Historic  Introduction. — From  the  very  earliest  times  we 
have  reason  to  believe  that  man  possessed  a  knowledge  of  the  deadly 
effects  of  liglitning,  and  we  read  of  various  methods  and  devices  that 
were  brought  into  use  by  numerous  savage  tribes  to  protect  themselves 
from,  it,  and  also  from  the  accompanying  thunder,  tiiough  it  is  not  evi- 
dent that  the  relationship  between  the  two  phenomena  was  known  ; 
indeed,  most  tribes  seemed  to  fear  the  thunder  more  than  the  lightning. 
Most  of  these  protective  agencies  consisted,  in  remote  times,  of  various 
incantations  with  occasional  complex  ceremonies  intended  to  appease  the 
deities  who  were  supposed  to  have  been  outraged.  Grecian  mythology 
affords  numerous  illustrations  of  the  worship  accorded  to  this  power, 
and  even  in  the  middle  ages  it  is  related  that  the  custom  of  the  ringing 
of  bells  originated  as  an  effort  for  protection,  it  being  believed  that  this 
ceremonial  observance  was  capable  of  neutralizing  the  bad  effects  of  the 
lightning.  The  early  philosophers,  Aristotle,  Lucretius,  Seneca,  Pliny, 
and  others,  record  not  only  the  deadly  effects  of  the  lightning-stroke,  but 
also  the  melting  of  buttons  and  coins  of  brass,  copper,  and  the  precious 
metals,  and  they  even  report  the  melting  of  such  coins  in  the  purse  with 
no  evil  effects  to  the  wearer. 

The  early  Italian  ])hysicists  developed  the  knowledge  of  frictional 
electricity,  and  Franklin,  in  1752,  actually  demonstrated,  by  means  of 
his  renowned  kite,  the  relationship  between  frictional  electricity  and 
lightning.  He  first  showed  what  part  the  clouds  played  in  the  ]>he- 
nomena  and  the  true  cause  of  the  thunder,  though  it  is  known  that 
Aristotle  had  made  some  shrewd  observations  on  the  relationship  be- 
tween thunder  and  lightning.  Since  the  time  of  Franklin's  work  the 
theoretic  researches  concerning  the  ]n'inciples  of  electricity  and  the  prac- 
tical applications  of  this  fluid  have  been  enormous,  and  at  the  present 
time  the  uses  to  which  electricity  in  its  various  forms  is  ])ut  are  unimagin- 
able. With  the  rapid  extension  of  the  economic  aj^pHcations  of  this 
force  there  has  necessarily  entered  an  increased  amount  of  I'isk  to  health 
and  even  to  life,  and  daily  the  loss  of  life  brought  about  by  contact  with 
different  forms  of  industrial  electricity  is  increasing  in  an  astounding 
manner. 

In  1891,  205  deaths  by  lightning  were  re])orte(l  in  the  United  States, 
and  292  in  1892;  and  in  the  five  years  1890  to  1895,  lightning  is 
credited  with  the  killing  of  1125  persons  in  this  country.     Boudin  col- 

245 


246       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 

lected  reports  of  2238  people  killed  in  France  during  the  twenty-eight 
years  from  1835  to  1863.  In  this  same  country,  from  1854  to  1864, 
there  were  967  deaths  from  this  same  cause.  In  Prussia  819  deaths 
from  lightning  were  reported  between  1869  and  1878.  Statistics  of 
sufficient  accuracy  are  not  yet  forthcoming  to  estimate  the  number  of 
lives  lost  by  the  modern  Juggernaut,  commercial  electricity,  but  it  is 
certain  that  the  victims  should  be  counted  in  recent  years  by  the  thou- 
sands rather  than  by  hundreds,  althougli  Boudin,  whose  statistics  are 
widely  quoted,  had,  previous  to  1891,  collected  reports  of  but  39  fatal 
cases  ;  these  figures  represent  but  a  small  proportion  of  the  actual  num- 
ber of  deaths,  since  they  are  limited  to  France,  where  the  use  of  indus- 
trial electricity  had  not  found  so  extended  an  application.  H.  P.  Brown 
collected  some  110  cases  of  death  resulting  from  contact  with  electric 
lighting  plants  alone,  all  of  which  occurred  in  1888  and  1889.  Biraud, 
in  1892,  made  a  calculation  that  there  had  occurred  in  France  300  deaths 
and  1000  accidents  of  a  lesser  degree.  Since  that  time,  however,  the 
use  of  high  potential  electric  machinery  has  increased,  and  such  forms 
of  api^aratus  are  now  to  be  found  in  almost  every  town  in  the  country. 
Electric  lights,  railways,  diiferent  forms  of  power  transmission  in  fac- 
tories and  stores  are  now  universal,  and  the  future  industrial  applications 
that  mav  be  made  are  boundless. 

The  principles  involved  in  accidents  due  to  lightning  are  fairly  well 
established,  but  with  reference  to  injuries  due  to  the  various  form  of 
industrial  electricity  there  are  many  theoretic  points  in  dispute. 

With  reference  to  the  action  of  lightning,  experimental  research  has 
shown  that  similar  effects  can  be  produced  by  the  use  of  frictional 
machines  and  Leyden  jars,  and  Richardson  ^  conducted  a  number  of 
experiments  on  animals  with  this  form  of  apparatus.  Nothnagel,  in 
1880,  also  made  a  number  of  observations,  and  further  pathologic 
study  in  cases  of  death  due  to  lightning  has  resulted  in  giving  a  fairly 
clear  picture  of  the  effects  produced  on  the  animal  body  by  this  agency. 
In  lightning  itself  the  electromotive  force  is  so  high  that  quantitative 
analysis  of  its  quantity  is  impossible. 

In  the  matter  of  commercial  electric  application  there  are  a  number 
of  questions  of  medicolegal  interest  closely  related  to  the  technicalities 
of  potential,  resistance,  and  amperage  of  electric  currents  which  are  of 
interest  in  the  general  discussion. 

Resistance  of  the  Body. — One  of  the  most  important  safe- 
guards of  the  human  body  against  the  passage  through  it  of  electric 
currents  is  its  high  degree  of  resistance.  This  is  very  frequently  stated 
to  be  from  1000  to  3000  ohms,  but  there  are  so  many  circumstances 
which  modify  this  that  didactic  statements  should  not  be  made  without 
taking  these  into  consideration.  Thus,  when  the  epidermis  is  perfectly 
dry,  its  resistance  to  the  passage  of  electric  currents  has  been  shown  by 
Jolly  to  be  very  high,  measuring,  in  Siemen's  units,  from  8000  to 
40,000  ohms  (Herold).  If  the  skin  is  thoroughly  moistened,  the  re- 
sistance of  the  body  may  register  but  500  ohms.     Herold  quotes  Bull- 

'  Medical  Times,  1869. 


RESISTANCE    OF    THE    BODY.  247 

arcl's  computations  on  259  males,  where  the  resistance  from  one  hand  to 
the  other  varied  from  550  to  1970  ohms,  and  in  a  series  of  measure- 
ments of  23G  men,  also  quoted  by  Herold,  the  averaije  resistance  was 
1184  ohms,  the  extremes  ranging  from  6 10  to  1870  ohms.  In  addition 
to  this  external  moisture  there  may  be  a  number  of  important  factors 
pertaining  to  the  internal  composition  of  the  tissues  through  which  the 
currents  may  pass  which  are  but  little  understood.  Thus  it  is  reported 
that  in  Basedow's  disease  the  electric  resistance  is  greatly  diminished ; 
the  same  is  said  to  be  true  of  hysteria. 

Voltage,  or  the  tension  current,  bears  an  important  relation  to  acci- 
dent and  injury.  As  this  factor  is  modified  so  greatly  by  the  character 
of  the  current,  whether  continuous  or  alternating,  and  by  the  quantity, 
or  amperage,  it  is  difficult  to  determine  just  what  relation  voltage  bears 
to  these  in  the  causation  of  disastrous  results.  Moreover,  as  pointed 
out  by  Tatura  and  Cunningham,  individual  variations  in  the  character 
of  the  heart  muscle  are  to  be  considered  ;  thus,  there  seems  to  be  ample 
ground  for  concluding  that,  in  addition  to  the  influence  exerted  by  the 
quality,  duration,  strength,  and  density  of  the  current,  other  factf>rs 
residing  in  the  heart,  of  a  probable  physiologic  nature,  exercise  consid- 
erable influence  in  the  production  of  fatal  etfects.  The  direction  in 
which  the  current  is  passed,  to  be  discussed  more  fidly,  is  also  an  im- 
portant item  ;  thus  Tatum  ^  has  shown  that  it  requires  much  stronger 
alternating  or  continuous  currents  to  produce  death  when  such  currents 
are  passed  from  the  head  to  the  lower  cervical  region  of  the  back  than 
when  such  currents  are  sent  through  the  head  to  the  thorax  or  through 
the  thorax.  In  fact,  it  is  in  the  determination  of  just  these  relationships 
that  most  discussion  is  relevant. 

E.  Grange  was  one  of  the  first  to  describe  a  case  of  death  due  to 
industrial  electricity,  and  later  he,  Brouardel,  and  Gariel  instituted  a 
series  of  experiments  to  determine  what  ^vere  the  important  factors  in 
death  bv  electricity.  A  more  extended  series  of  researches  was  then 
instituted  by  d' Arson val  and  Brown-Sequard  ^  with  both  constant  and 
alternating  currents.  They  confined  their  attention  mainly  to  the  ques- 
tion of  the  cause  of  death  (see  later),  but  on  the  subject  of  the  relation- 
ship of  voltage  and  character  of  current  they  observed  that  the  current 
derived  from  a  primary  coil  is  more  dangerous  to  life  than  that  obtained 
from  the  secondary  coil,  especially  when  this  was  provided  with  a  con- 
denser. With  the  Gram  alternating  machine,  then  in  use,  they  were 
able  to  kill  guinea-pigs  with  a  current  of  120  volt<,  but  with  a  battery 
giving  a  current  of  420  volts  death  could  not  be  produced  unless  the 
current  was  interrupted  very  rapidly  and  its  application  continued  for 
a  considerable  time.  In  their  opinion  death  was  produced  in  this  case 
by  tetanic  rigidity  producing  asphyxiation  rather  than  by  the  direct 
action  of  the  current  on  the  heart  or  the  nervous  system.  They,  more- 
over, conchide  that  the  Gram  continuous  current  machine  is  rendered 
dangerous  only  by  the  introduction  of  a  secondary  coil   with  a   rapid 

»  Xeiv  York  Medical  Journal,  1890,  p.  287  ;  Electrical  World,  1890,  p.  319. 
^  Compfes  rendiis  de  l' Academic  des  Sciences,  April  4,  1887,  vol.  civ.,  p.  978. 


248       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 

interrupter.  The  extensive  investigations  of  Dr.  F.  Peterson  and 
Messrs.  Brown  and  Kennelly  at  the  Edison  Laboratories  and  at  Col- 
umbia University  ^  have  demonstrated  that,  for  lower  animals  at  least, 
continuous  currents  of  high  voltage  do  less  harm  than  alternating  cur- 
rents of  the  same  or  even  greatly  reduced  voltage.  Thus,  in  his  re])ort 
on  the  physiologic  action  of  the  effects  of  various  kinds  of  electric 
currents,  Dr.  F.  Peterson  says  :  "  It  can  very  readily  be  demonstrated 
that  alternating  currents  are  more  powerful  and  severe  than  a  continu- 
ous current  on  its  mere  interruption.  As  a  current  will  stimulate  a 
nerve  in  something  like  y^^g-  of  a  second,  it  is  clear  that  when  the 
continuous  current  is  closed  on  a  body  for  a  limited  space  of  time  there 
is  but  one  shock  at  the  closing  and  one  at  the  opening  of  the  circuit ; 
whereas  with  an  alternating  for  the  same  interval  of  time  the  shocks 
are  twice  as  long  and  as  many  in  number  as  there  are  reversals  of  the 
current  per  second.  If  the  stimuli  are  too  numerous,  say  over  65  per 
second,  a  condition  of  tetanus  is  produced  in  the  muscles  supplied  by 
the  nerves  stimulated.  The  same  fact  holds  good  as  to  currents  of  any 
strength. 

"  From  this  it  must  appear  plain  that  a  continuous  current,  say  of 
1600  volts  electromotive  force,  is  sufficient  to  cause  death,  then  an  alter- 
nating current  of  much  less  than  half  that  voltage  must  be  fatal  under 
the  same  conditions."  In  his  series  of  experiments  dogs  were  not 
injured  by  continuous  currents  of  1400  volts,  but  alternating  currents 
of  300  volts  caused  great  distress  in  two  seconds.  With  4000  vibra- 
tions a  miinite,  and  in  tlie  strength  of  570  volts  the  dogs  were  killed 
at  the  expiration  of  three  seconds.  With  the  same  voltage  and  an 
increasing  number  of  interruptions  the  fatal  quality  of  the  electricity  is 
manifest.  Thus  their  dog  7  was  killed  in  five  seconds  with  250  volts 
with  288  alternations  a  second,  and  dog  8  was  killed  by  160  volts  with 
the  same  number  of  alternations  a  second. 

Since  at  about  this  time  (January  1,  1889)  the  present  electrocution 
laws  of  New  York  State  were  to  go  into  effect,  further  experiments 
were  conducted  by  Drs.  Peterson,  Doremus,  Ingraham,  and  others  on 
animals  of  greater  weight  than  dogs  in  order  to  approximate  the  condi- 
tions presumably  present  for  man  and  thus  gain  some  exjierimental 
standards  by  which  the  electrocution  methods  could  be  carried  on  suc- 
cessfully. Two  calves,  weighing  125  and  145  pounds  respectively,  were 
killed  l)y  770  and  750  volts  with  alternating  currents  in  a  few  seconds, 
and  700  volts  killed  a  horse  weighing  1230  pounds.  In  the  physiologic 
exj^eriments  made  preparatory  to  the  use  of  the  present  electrocution 
methods  it  seemed  fairlv  well  established  that  no  human  being:  could 
withstand  the  alternating  current  of  1500  volts,  and  300  had  produced 
death,  while  for  the  continuous  current  it  was  necessary  that  over  3000 
volts  were  requisite  to  bring  about  fatal  results.^ 

Grades  of  Accident  and  Injury. — It  is  not  purposed  to  discuss 

^  The  Crmiparative  Danger  of  Life  of   the  Alternating  and  Continuous   Currents^ 
H.  P.  Brown,  New  York. 

^  Cunningham  on  Amperage  (see  Cunningham),  Neio  York  Med.  Jour.,  1890,  p.  287. 


GRADES    OF    ACCIDENT    AND    INJURY. 


249 


in  this  section  every  variety  of  grade  of  iiiorl)i(l  process  induced  by  the 
shock  of  liglitninii-  or  inchistrial  electricity,  for  it  is  apparent,  from 
reference  to  an  iiiunense  literatnre,  that  sucli  are  very  varied  in  their 
manifestations,   ranging    from    the    slightest    nervous    shock    to   death. 

) 


I 


Fig.  17.— Burn  of  eleotrical  current  of  1800  volts  and  14,000  volt-auiperes,  showing  two  blisters 
one  broken,  at  tlie  site  of  the  entrance  of  the  current  (Kratter).  ' 

When  the  injury  comes  about  by  other  means  than  by  the  direct  current, 
as  when  a  lineman  falls  from  the  pole  by  reason  of  tlie  loss  of  muscular 
control  induced  by  touching  a  "  live  Avire,"  a  series  of  injuries  may 
result  having  nothing  to  do  Avith  the  question. 


mam 


Fig.  18. — Skin  of  back  of  same  case  (Fig.  17),  showing  burn  at  point  of  contact-exit  of  current 
witli  extensive  blood-extravasation  (Kratter). 

This  latter  class  may  be  dismissed  from  the  present  discussion,  as 
the  injuries  are  due  to  the  fall  rather  than  to  the  electricity,  though  in 
some  fatal  cases  it  may  be  difficult  justly  to  place  the  responsibility.     A 


250       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 

great  variety  of  injuries  occur  in  this  way — fractures,  dislocations, 
sprains,  bruises,  and  open  wounds.  All  these  accidents  have  an  im- 
portant medicolegal  bearing,  as  the  initial  cause  is  the  electric  shock. 

While  the  direct  action  of  lightning  and  industrial  electric  currents 
may  produce  much  the  same  character  of  results,  it  is  convenient  to 
consider  the  symptoms  of  each  separately. 

Minor  Injuries  from  I/ightning. — These  may  consist  of  simple 
mental  shock  or  intense  and  prolonged  nervousness,  a  symptom  which 
is  by  no  means  mfrequent  with  many  people.  If  an  electric  bolt  strikes 
in  the  near  vicinity,  a  mild  stunning  may  be  experienced,  with  a  sense 
of  suffocation,  which  will  in  all  probability  pass  oflP  quickly,  or  in  some 
nervous  and  hysteric  persons  an  attack  of  hysteric  crying  may  be  brought 
on.  In  such  patients  suppression  of  menstruation  has  been  produced, 
and  cases  of  abortion  have  been  reported.  In  the  severer  cases  loss  of 
consciousness,  which  may  he  transitory  or  much  prolonged,  is  not  rare, 
and  this  is  frequently  followed  by  various  phenomena,  ranging  from 
numbness  and  prickling  of  various  areas  of  the  body  (paresthesise)  to 
anesthesia  or  analgesia  of  the  extremities  or  side  of  the  face,  with  diffi- 
culty in  mastication.  Paralyses  are  by  no  means  uncommon,  occurring 
in  the  muscles  of  the  arms  and  legs  ;  ptosis  and  strabismus  have  been 
reported  ;  deafness  and  loss  of  smell  and  taste,  with  paralysis  of  the 
bladder  and  rectum  and  motor  incoordination,  may  be  present. 

In  Nothuagel's  cited  experimental  work  the  development  of  periph- 
eral paralyses,  both  motor  and  sensory,  was  a  prominent  feature ;  and 
among  many  other  reports  of  similar  phenomena  those  of  G.  de  Savigny' 
and  Charcot's^  are  among  the  most  striking.  They  describe  cases  of 
peripheral  paralyses  of  a  marked  hysteric  character.  Traumatic  neu- 
roses of  a  most  refractory  kind  are  reported  by  a  large  number  of 
observers,  notably  Freund,^  Frankl-Hochwart,*  and  Kratter.  In  chil- 
dren, Demme*"  has  described  a  type  of  spinal  paralysis  following  light- 
ning-stroke. 

Not  only  do  functional  neuroses  follow  the  lightning-stroke,  but 
there  are  cases  on  record  in  which  actual  anatomic  lesions  have  super- 
vened. The  literature  of  the  subject  is  so  extensive  that  only  a  few  of 
the  more  carefully  observed  cases  can  here  be  cited.  Thus  Leber  ^  and 
Pagenstecher '^  both  describe  the  production  of  changes  in  the  optic 
nerve,  with  temporary  or  permanent  blindness,  and  Laker*  describes  in 
great  detail  the  occurrence  of  blindness  following  a  lightning-stroke, 
which  blindness  was  produced  by  extensive  hemorrhages  into  the  retina. 

^  G-.  de  Siivigny,  Revue  7ned.  frnn^nise  et  ct ranger,  \^%\. 
^  Charcot,  Lecon  du  mordi,  a  la  SalpCiriere,  1889. 

^  Freund,  "  TJeber  einer  Schreckneurose  nach  Blitzschlag, "  Deutsche  medicinische 
Wochensckrift,   1891. 

*  Y .  Fraiikl-Hochwart,  ' '  Ueber  Keraunoiieurose, ' '  Zeitschriftfur  klinische  Medicin, 
Bd.  xix.,  Th.  5,  6. 

*  Demme,  Virckow's  Jahresbericht,  1883,  S.  626. 

*  Leber,  v.  Graefe's  Archh\  Bd.  xxviii. 

'  Pagenstecher,  ArcMv  fur  Ohrenlieilkunde,  Bd.  xiii. 

8  Laker,  "  Ein  Fall  von  Augenafiection  durch  Blitzschlag, " -^rcAw /?/?•  Augen- 
heUkunde,1884,  S.  161. 


MINOR    INJURIES    FROM    LIGHTNING.  251 

Von  Limbeck  ^  reports  a  case  of  right-sided  paresis,  with  contractures 
and  increased  reflexes,  following  liohtning-stroke,  in  wliich  there  were 
hemorrhages  in  tlie  brain  ;  thus,  in  a  sense,  corroborating  the  evidence 
derived  from  experinu'utal  researches  on  animals. 

Insanities,  usually  of  the  maniacal  type,  have  been  known  to  occur 
closely  following  lightning-stroke.  Thus  Taylor^  cites  an  instance  of  a 
patient  who  became  delirious  for  three  days,  and  on  recovery  was  found 
to  have  lost  his  memory  completely. 

From  a  medicolegal  point  of  view  the  traumatic  neuroses  afford  an 
extensive  field  for  careful  and  extended  research.  Among  the  many 
cases  of  malingerers  or  quasimalingerers  there  is,  nevertheless,  a  con- 
siderable number  of  people  who  suffer  acutely  and  deeply  from  the 
effects  of  an  electric  shock.  The  space  at  hand  does  not  warrant  the 
com[)lete  discussion  of  such  cases ;  suffice  it  to  say  that  there  are  per- 
haps but  few  questions  of  recent  years  that  excite  more  interest  than  do 
those  related  to  the  traumatic  functional  neuroses. 

The  burns  that  may  be  produced  are  of  every  conceivable  variety. 

A  variety  of  attending  phenomena  are  recorded — flashing  in  the 
eyes,  buzzing  in  the  ears,  general  tremor,  going  on  to  rhythmic  convul- 
sions, with  or  without  loss  of  consciousness.  Persons  seen  while  in  this 
stage  of  muscular  contraction  have  been  described  as  cyanotic,  with 
dilated  pupils.  The  respiration  is  likely  to  be  stertorous,  or,  if  the 
tetanus  is  sufficiently  severe,  there  are  but  few  respiratory  movements. 
The  pulse  is  generally  feeble,  sometimes  full  and  soft,  and  sometimes  it 
seems  as  though  the  h^art  were  beating  very  rapidly  and  irregularly. 
Under  experimental  control,  in  animals,  there  are  certain  discrepancies 
in  the  accounts  given  by  various  observers,  but  it  would  seem  probable 
that  the  heart  bears  the  chief  burden  of  the  electric  action,  and  hence 
reliable  clinical  observations  in  cases  of  accident  are  wanted. 

Pathology. — A  great  variety  of  external  lesions  resulting  from 
lightning  and  industrial  electricity  have  been  described.  In  some 
fatalities  due  to  these  agents  no  discoverable  traces  have  been  elicited. 
In  many  there  have  been  found  minute  bluish  punctiform  spots,  or  very 
fine  reddish  spots  on  the  hands  and  feet,  produced  by  the  outflowing 
electric  currents,  and  in  still  others  numerous  fine  ecchymotic  extravasa- 
tions may  be  irregularly  distributed  over  a  large  area  of  the  body. 

In  by  far  the  greater  number  of  cases  burns  of  various  degrees  are 
present.  These  may  vary  from  simple  vesication  to  charring  of  the 
flesh,  even  to  the  bone.  Many  are  produced  by  the  burning  of  the 
clothes,  but  others  are  due  to  the  action  of  the  lightning  itself. 

Following  death  from  lightning,  Kratter  and  others  have  described 
cases  in  which  the  effect  of  the  electric  transmission  was  evidenced  only 
by  a  disruptive  lesion  of  the  hands.  Here  it  would  appear  that  the 
electric  bolt  had  streamed  out  of  the  finger  and  torn  its  way  through 
the  skin  in  its  passage. 

It  is  of  considerable  medicolegal  importance  to  note  that  in  a  number 

^  Von  Limbeck,  Praqer  medicinische  Wochensch7'ift,  1891,  Bd.  xvi.,  No.  13 
'  Taylor,  Medical  Jurisjyrudence. 


252       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 

of  cases  there  have  been  reports  of  similar  disruptive  lesions,  which 
have  closely  resembled  wounds  produced  by  a  blunt  dagger. 

Among  the  minor  lesions,  charring  of  the  hair  should  be  borne  in 
mind.  Most  of  the  burning  lesions  are  associated  with  the  electric 
lighting  and  railway  systems.  With  the  work  of  linemen  working  on 
overhead  wires,  lesions  due  to  falling  should  be  considered  when  there 
may  be  doubt  in  the  diagnosis  of  the  cause  of  the  injury.  In  such  cases 
the  burns  are,  for  the  most  part,  situated  on  the  hands,  though  they  may 
at  times  show  very  bizarre  distributions.  The  results  of  the  falling  are 
multifarious,  and  should  be  considered  as  purely  surgical  accidents. 

Distinct  surface  markings  may  be  manifest  in  persons  who  have 
sought  protection  from  lightning  under  trees.  The  lightning,  in  its 
descent,  is  thought  to  follow  the  line  of  least  resistance,  which  usually 


Fig.  19. — Lij;ljtiiiiiy-iiiark>  t  Ini,  i  imlinunl  Ttxl- i'>(i(jk  of  Stirgenj). 


coincides  with  the  path  of  greatest  moisture.  This  may  be  in  the 
cambium  layer,  just  beneath  the  bark,  as  claimed  by  Strieker,^  or  the 
bolt  may  follow  down  the  moistened  bark,  then  jump  to  the  head,  neck, 
or  shoulder,  usually  producing  a  distinct  burn.  From  there  its  course 
may  be  marked  on  the  outside  of  the  body  as  a  fine,  irregular,  zig-zag 
line  of  extravasation,  ending  at  times  at  the  nates  or  traveling  down  to 
the  legs.  In  some  instances  the  markings  on  the  arms  or  trunk  are 
feathery  (see  Fig.  19).  When  the  person  is  leaning  against  the  tree  or 
is  standing  free,  diiferences  may  be  noted  in  the  character  of  the  burn- 
ing that  may  occur.  Strieker,  in  his  memorable  study,  claims  the  fol- 
lowing features  : 

1  W.  Strieker,  "  Die  Wirkung  des  Blitzes  auf  den  menschlichen  Korper, "  Virchow's 
Archiv,  1801,  Bd.  xx.,  S.  45. 


MINOR    INJURTHS    FROM    LIGHTNING.  253 

1.  Ill  those  cases  Avliere  the  person  may  be  leaning  against  the  tree, 
side  of  a  house,  etc.,  the  lightning  usually  enters  the  point  of  contact. 
This  is,  as  a  rule,  the  shoulder  or  the  side  of  the  neck,  where  a  marked 
burning  takes  place,  ^vith  extravasation  of  bh^od  and  injection  of  the 
blood-vessels,  which  are  often  prominently  spread  out  as  hand-like  or 
leaf-like  blotches.  From  the  shoulder  a  delicate  line  may  be  traced  to 
the  back  and  down  along  the  spinous  processes  to  the  nates,  becoming 
smaller  as  it  descends  and  more  superficial.  Here,  by  reason  of  the 
clothing,  two  things  may  occur  :  (a)  The  electric  stream  may  be  carried 
off  by  the  clothing,  wliieh  is  destroyed  or  torn  off  from  the  lower  limbs, 
or  the  charge  may  break  through  the  clothing,  carrying  away  a  localized 
fragment  more  or  less  circular  in  general  outline,  [b)  If  the  charge  is 
carried  by  the  skin,  the  more  prominent  parts,  the  trochanters  of  the 
long  bones,  are  very  apt  to  l)e  severely  burned.  The  streak  goes  down 
on  one  side  or  sometimes  down  both  limljs,  growing  smaller,  and 
produces  burns  on  the  knees.  It  may  jump  to  the  shoes,  entirely 
destroying  them,  or  go  on  out  through  the  stocking  or  the  bottom  of  the 
foot  through  the  shoe,  producing  here  many  fine  punctiform  hemorrhages 
in  the  sole  of  the  foot. 

2.  In  persons  not  leaning  directly  against  the  tree  or  building  the 
stream  may  jump  to  the  head  bones,  producing  at  times  instant  death, 
or,  if  it  passes  by  means  of  the  skin,  the  streak  noted  is  more  apt  to 
travel  in  the  anterior  part  of  the  body  to  the  mguinal  region,  producing 
severe  burns  about  the  genitals. 

The  electric  current  may  also  traverse  the  deeper  portions  of  the 
body.  The  lesions  then  produced  are  extensive,  and  will  be  discussed 
under  the  head  of  internal  findings.  Burning  of  the  hair  is  one  of  the 
most  constant  features  in  such  accidents,  occurring,  according  to  Strieker 
and  other  observers,  even  when  no  other  signs  of  injury  are  to  be 
found,  and  hence  it  is  to  be  considered  as  one  of  the  most  important 
signs  of  the  conduction  of  the  electric  charge. 

In  some  instances  death  has  occurred  so  ra]iidly  that  the  bodv  has 
preserved  the  attitude  in  which  it  was  struck  and  has  shown  absolutely 
no  external  evidences  of  the  cause  of  death.  Thus  Taylor  cites  the 
cases  of  5  negroes  who  were  simultaneously  jirostrated  by  a  single 
lightning-stroke.  Three  of  them,  2  being  children,  were  instantly 
killed.  The  only  mark  found  on  one,  an  adult  female,  was  a  burnt 
spot,  the  size  of  a  dollar,  under  the  right  axilla,  and  this  woman's 
clothes  were  set  on  fire. 

As  there  have  been  great  numbers  of  physiologic  experiments  made 
with  commercial  electric  currents,  the  knowledge  of  the  external  lesions 
produced  by  them  is  more  accurate  and  deductions  drawn  are  more 
valuable.  Grange,^  in  1882,  had  the  opportunity  to  observe  2  fatal  cases 
in  the  Tuillerics,  and  was  perhaps  the  first  to  give  the  autopsy  findings 
in  cases  of  death  produced  by  commercial  electric  currents.     Two  years 

^  "  Des  accidents  produits  par  relectricite  dans  son  emploie  industrial,"  Annates 
d' Hygiene  publique  et  de  Medicine  legale,  1885,  3,  13,  p.  53. 


254       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 

later,  with  Brouardel  and  Gariel/  he  made  further  observations  of  an 
experimental  nature,  which  have  been  the  basis  of  our  present  experi- 
mental standards.  The  work  of  Brown-S^quard  and  d'Arsonval 
followed  closely  after,  while  Peterson,  Brown,  Knapp,  Kennelly,  and 
Doremus  were  among  the  earlier  American  experimenters.  Kratter 
and  Friedenger  were  among  the  few  German  investigators  with  electric 
machinery  previous  to  1891.  The  American  workers  were  the  most 
active. 

The  external  lesions  produced  by  these  commercial  currents,  both 
when  under  experimental  control  or  when  brought  about  by  unknowing 
contact,  have  been,  for  tlie  most  part,  burns  of  various  degrees.  A 
large  number  of  interesting  internal  findings  are  recorded,  liowever, 
which  will  l)e  further  discussed. 

Internal  Pathologic  Lesions  Due  to  Lightning. — The  observations 
of  Rindfleiseh "  and  Langerhans  '^  are  among  the  earlier  well-recorded 
postmortem  findings  in  death  by  lightning,  and  may  well  be  quoted 
here.  Twelve  minutes  after  death  rigor  mortis  was  w^ell  developed. 
The  head  and  neck  were  livid  purple  and  suffused.  The  eyelids  partly 
covered  the  eyes,  the  uncovered  conjunctivae  shoMang  marked  hyperemia. 

Observations  of  a  positive  character  on  the  internal  viscera  have 
been  very  few.  The  early  cases  of  Aragos'  collection  are  interesting 
mainly  because  of  the  notes  made  relating  to  the  melting  of  precious 
metals,  and  later  cases  are  on  record  where  the  shoes  have  been  torn  off 
with  great  violence  by  the  lightning-bolt  and  yet  no  marked  effects 
experienced  by  the  individual. 

Schneider  was  among  the  first  to  record  the  fact  that  bones  maybe 
broken  and  blood-vessels  ruptured.  The  early  autopsies  of  Rindfleiseh 
and  Langerhans  show^ed  the  following  :  The  internal  organs  were  not 
involved.  The  brain  was  hyperemic,  but  microscopically  not  altered  (as 
studied  by  contemporaneous  methods).  Tourdes  records  a  case  of  rup- 
ture of  the  membrana  tympani  and  also  breaking  of  bones  and  of  the 
skull.  He  first  showed  that  no  changes  occurred  in  the  spectrum  analy- 
sis of  the  blood.  The  abdominal  viscera  may  suffer  gross  rupture  ;  they 
may  be  torn  and  hemorrhagic,  l)ut  few  changes  of  a  minute  character 
have  thus  far  been  described.  Gross  lesions  of  the  brain  and  meninges 
have  also  been  quite  frequently  observed,  but  no  observations  on  the 
cytologic  changes  of  the  brain  cortex  or  basal  ganglia  are  available  for 
comparison  with  changes  induced  during  the  experimental  studies  which 
have  been  made  of  recent  years. 

Internal  Lesions  in  Death  Due  to  Industrial  Electricity. — Pathog- 
nomonic lesions,  for  the  most  part,  have  been  absent  in  these  cases. 
Numerous  experiments  have   been  made  on  animals  to  determine  the 

1  Brouardel,  Gariel  et  Grange,  "  Sur  un  phenomene  observe  chez  les  animaux 
soumis  a  1 'action  des  courants  electriques  intense,"  Comptes  rendues  de  la  Societe  de 
Bioloffie,  Nov.  29,  1884. 

''  Rindfleiseh,  "  Ein  Fall  von  Blitzschlag, "  Virchoiv^s  Arehiv,  1882,  Bd.  xxv., 
S.  471. 

'  Langerhans,  "  Zwei  Falle  von  Todtung  durch  Blitzschlag,"  ibid.,  1862,  Bd. 
xxiv.,  S.'200. 


PLATE  2. 


Fifj  2. 


Fiji 


Fij3. 


Fio.  1. — Dura  of  guinea-pig  killed  by  the  clcotric  ourrcnt,  sliowing  iiiarlvcd  suhiliiral 
hemorrhage. 

Fio.  "2. — Brain  of  same  animal,  showing  contusion,  hemorrhage,  and  superficial  burn- 
ing of  the  meninges  and  convolutions  of  the  right  hemisi)here.  Extensive  ijitcrmcningeal 
hemorrhage  is  also  present. 

Fri;.  .3. — Rase  of  l)rain  of  same  animal  with  extensive  hemorrhage  of  tlie  dura,  espe- 
cially in  the  middle  fossse.     iKr.\ttkr.) 


MLN'OR    INJURIES    FROM    LIGHTNING.  255 

causes  of  death  aud  the  character  of  the  lesions.  The  discussion  of  the 
causes  of  death  has  been  referred  to  another  paragraph.  The  earliest 
experimental  investigations  made  on  animals  with  the  modern  industrial 
electric  currents  that  are  of  service  in  the  present  joresentation  were 
those  of  Grange,  Gariel,  and  Brouardel,  made  in  1884,  and  those  of 
Brown-Sequard  and  d'Arsouval '  in  188G  and  1887.  It  should  be 
borne  in  mind,  however,  that  Priestley,  as  early  as  1766,  killed 
animals  by  static  electricity,  and  that  at  that  time  numerous  experi- 
menters followed  him,  notably  Fontana,  the  Italian  physicist.  The 
observations  of  Xotlmagel  in  1880  are  also  worthy  of  record  in  this 
relationship. 

D'Arsonval's  results  will  be  referred  to  under  the  ])aragraph  on  causes 
of  death,  since  he  was  interested  from  the  physiologic  side  of  the  problem 
only.  From  the  pathologic  point  of  view  the  investigations  of  Peterson 
and  Doremus,  conducted  iu  the  Edison  Laboratories  in  1888,  are  of 
importance.  Postmortem  findings  in  the  animals  already  referred  to 
in  the  opening  paragraphs  of  this  discussion  showed  the  lungs  to  be 
normal  in  nearly  all  cases.  The  heart  was  engorged  on  the  right  side, 
and  empty  on  the  left ;  the  abdominal  viscera  were  normal,  save  for 
marked  hyperemia.  In  some  dogs  slight  extravasations  in  the  muscles 
beneath  the  electrodes  ^vcre  observed.  The  nerve  parenchyma  of  the 
sciatic  nerve  was  normal,  as  was  also  the  spinal  cord  (older  methods  of 
investigation  were  employed). 

Animal  experiments  made  by  Kratter  ^  within  recent  years  on  mice, 
guinea-pigs,  rabbits,  cats,  and  dogs  show  certain  signs  regarded  by  him 
as  more  or  less  pathognomonic  of  the  condition.  Subj)ericardial  and 
subpleural  ecchymoses,  and  more  particularly  subendocardial  ecchymotic 
extravasations,  occurred  in  most  of  his  cases,  combined  with  bloody 
emphysema  of  the  larger  bronchial  ramifications.  These  signs,  when 
taken  in  conjunction  with  the  external  burns,  are  believed  by  him  to  be 
sufficient  to  make  the  diagnosis  "  death  bv  electrieitv."  Rio;or  mortis 
occurred  very  rapidly  and  persisted  for  a  distinct  peri(^d  of  time.  Macro- 
scopically,  changes  in  the  brain  aud  spinal  cord  Mere  not  prevalent, 
though  in  some  there  were  subdural  and  intermeningeal  hemorrhagic 
extravasations.  Microscopically,  minute  capillary  hemorrhages  Avere 
also  observed.  These  are  of  interest  by  way  of  comparison  with  similar 
findings  by  Peterson,  and  in  cases  of  electrocution,  as  rejiorted  by  Van 
Gieson.  Changes  in  the  morphology  of  the  blood  have  been  emplia- 
sized  by  earlier  observers,  but  the  careful  work  of  Kratter  and  other  recent 
writers  would  seem  to  prove  quite  conclusively  that  such  do  not  occur  save 
at  the  sites  of  electrode  contact.  More  recently  Cunningham  ^  has  shown 
that  if  the  thorax  be  opened  immediately  following  death,  due  to  strong 
continuous  currents  or  alternating  currents  of  meditmi  frequency,  the 
heart  on   close  examination  will  be  found  to  show  a  minute  quivering 

'  D'Arsonval,  "La  mort  par  I'electricite  clans  Tindustrie, "  Comptes rendus,  April 
4,  1887,  vol.  civ.,  p.  988. 

^  Kratter,  Der  Tod  durch  Elektridtdt,  Vienna,  1896,  S.  61  et  seq. 
3  New  York  Medical  Journal,  Oct.  28,  1899,  pp.  581  and  610. 


256       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTEICITY. 

throughout  its  entire  muscular  substance.  While  the  coordinate  beats 
of  the  ventricles,  as  a  rule,  are  absent,  the  numerous  isolated  bundles 
of  muscle-fibers  will  be  found  alternately  to  contract  and  relax  Avith 
vigor  in  different  parts  of  the  ventricle  ;  and  as  the  right  and  left  auri- 
cles become  gradually  distended,  this  irregular  quivering  of  the  muscle 
bundles  grows  feebler  and  feebler  until  every  trace  of  muscular  contrac- 
tion has  disappeared.  This  state  of  delirium  cordis,  or,  as  Cunningham 
prefers  to  call  it,  "  fibrillary  contraction,"  as  the  cause  of  death,  was  first 
pointed  out  by  Cunningham  and  also  independently  by  Prevost  and  Battelli.' 

The  nervous  tissues  have  been  carefully  searched  for  pathologic 
changes,  and  it  has  been  only  within  recent  time  that  distinct  changes 
have  been  found.  It  seems  not  improbable  that  changes  of  importance 
would  be  found  bv  the  newer  technical  methods  of  investigation,  but 
thus  far  but  few  workers  have  employed  the  Xissl  methods,  or  modifi- 
cations of  the  same.  Kratter's  observations  were  made  by  the  older 
methods,  and  he  found  no  special  cell  changes.  He  confirms  the  obser- 
vations made  by  Peterson,  Spitzka,  Van  Gieson,  and  others  that  minute 
capillary  hemorrhages  in  the  perivascular  sjxaces  are  present,  especially 
m  the  superficial  layers  of  the  cortex,  but  those  he  distinctly  shows  are 
not  universal  and  cannot  be  regarded  as  of  sufficient  moment  on  which 
to  base  a  pathologic  diagnosis  of  death.  He  concludes,  however,  that 
he  believes  that  minute  changes  not  known  to  our  present  technical 
methods  are  responsible  for  death  by  electric  currents.  More  recently 
Corrado "  has  shown  that  such  minute  changes  may  be  demonstrated  by 
means  of  the  more  modern  histochemical  microtechnical  methods. 

Corrado's  conclusions  may  be  summarized  as  follows  : 

The  continuous  electric  current  derived  directly  from  the  commutator 
and  applied  to  robust  adult  dogs  weighing  from  2.5  to  20  kilos  (5  to 
50  pounds),  one  electrode  being  placed  to  the  head  and  the  other  to  the 
lower  portion  of  the  spinal  cord,  with  a  voltage  of  from  720  to  2175 
volts,  and  an  amperage  of  20  to  30,  or  in  two  dogs,  10  to  12  amperes, 
produced  death  in  every  instance.  Death  occurred  immediately  and 
w^as  not  influenced  I>y  artificial  respiration.  On  the  closure  of  the  cir- 
cuit the  animal,  without  emitting  a  cry,  became  rigid,  and  all  the 
muscles,  especially  those  of  the  back,  contracted  violently,  producing  a 
pronounced  o])isthotonos.  This  rigidity  persisted  for  from  one-half  to 
one  minute  after  the  cessation  of  the  flow  of  the  current.  Respiration 
was  arrested  from  the  first  moment  of  the  passage  of  the  current. 

An  examination  of  the  ganglion  cells  of  the  brain  and  spinal  cord 
by  the  newer  methods  of  Xissl  and  also  by  the  method  of  Golgi  showed 
a  number  of  interesting  lesions,  the  importance  and  interpretation  of 
whicii  are  only  just  beginning  to  be  appreciated. 

Corrado  describes  changes  as  occurring  in  the  external  shape  and 
configuration  of  the  cell-body,  changes  of  the  cytoplasm  and  of  the 
processes  (see  Plate  3)  : 

^  Cornptes  rendt/s  de  V Acadewi e  des  sciences.  March  13  and  27,  1899. 
*G.  Corrado,  "  Di  alcune  alterazione  delle  cellule  nervose  nella  morte  per  ellettri- 
cita,"  Atti.  d.  R.  Accnd.  Med.  chir.  di  Napoli,  1898,  vol.  lii. 


Cytologic  Changes  in  Death  by  Electeicity  (Coerado). 

The  cells  in  this  illustration  for  the  greater  part  are  from  the  medulla.  Figs.  8,  9, 
18,  19,  20,  24,  26,  27,  28,  and  29  are  from  the  cerebral  cortex,  frontal  and  parietal  lobes. 
Fixation  has  been  by  means  of  absolute  alcohol  ;  staining  by  methylene-blue  or  thionin. 

Figs.  1-4. — Cells  variously  contorted. 

Fig.  5. — Unilateral  erosion  of  cell  and  of  nucleus. 

Fig.  6. — Laceration  of  side  of  cell  with  disiippearance  of  nucleus  and  nucleolus. 

Fig.  7. — Cell  with  irregular  contour  and  irregular  chromatic  distribution. 

Figs.  8,  9. — Disappearance  of  part  of  chromatic  substance.  Fig.  8  shows  loss  of 
nucleolus. 

Figs.  10-12. — Irregular  distribution  of  the  chromatic  substance  with  partial  or  com- 
plete loss  of  nucleus. 

Fig.  13. — Irregular  distribution  of  chromatic  substance  with  vacuolization. 

Figs.  14-x6.— Aggregated  chromatic  substance.  In  Figs.  15,  16,  the  nucleolus  is  outside 
of  the  nucleus. 

Figs.  17-20. — Various  deformities  of  cells,  eccentricity  of  the  nucleus,  loss  of  chro- 
matic substance.     Chromatolysis  both  central  and  peripheral. 

Fig.  21. — Partial  perinuclear  chromatolysis.  Hj-perchromatosis  of  nucleus  and 
nucleolus. 

Figs.  22,  23. — Nucleolus  penetrating  the  nuclear  membrane. 

Figs.  24,  25. — Irregular  distribution  of  chromatic  substance.     Nucleolus  peripheral. 

Figs.  26-29. — Cerebral  cells  fixed  with  sublimate  which  show  regular  vacuolization, 
and  causing  regular  deformities  of  the  nucleus. 


PLATE  3. 


4t 


-*w   \^>^     K    >>*;"  --"»"  '/^^  "  --^^- 


19 


■'S^ 


2^ 


f 


Z5 


■  ■-:X>.oJ^-  ■«..  I*- 


'-^i^'' 


^f 


MINOR    INJURIES    FROM    LIGHTNING.  257 

A.  Chaiii^os  in  the  cell  contour:  (1)  Noteworthy  and  various  deform- 
ities, erosions,  jau-i^ed  outlines,  lacerations,  and  even  severe  destruction 
of  the  cell  outline.  (2)  The  contour  of  the  cell  became  hazy  and  dif- 
fuse.    (3)  In  some  cases  the  prot()])lasm  became  granular  on  one  side. 

B.  Internal  cell  changes:  (1)  A  grade  of  dissolution  of  the  chro- 
matic substances  witli  j)o\vdery  granulations  was  observed.  The  cell 
contents  were  more  homogeneous  and  showed  the  beginning  changes  of 
chromatolysis.  (2)  Frequent  and  pronounced  vacuolation  (perhaps 
artefact).  (3)  The  chromatic  substances  had  a  slight  tendency  to 
become  dispersed  in  the  remainder  of  the  cell-body,  at  times  in  distinct 
collections,  which  in  certain  parts  of  the  cerebral  cortex  had  a  special 
arrangement.  These  collections  of  chromatic  j)articles  were  not  dis- 
posed in  the  direction  of  the  passage  of  the  electric  current.  (4)  The 
nucleus  is  quite  resistant.  It  may,  however,  be  modified  in  shape, 
become  diminished  in  size,  or  may  entirely  disappear.  The  contour  of 
the  nucleus  mav  be  irregular  or  even  an<);;ular.  The  chromatic  substance 
of  the  nucleus  may  be  irrf^gularly  disposed,  granular,  arranged  in  fine, 
irregular  filaments  at  the  periphery,  or  it  may  entirely  disap]>ear,  leaving 
the  nucleus  colorless.  The  position  of  the  nucleus  may  vary.  A  cer- 
tain tendency  is  manifest  for  it  to  be  located  on  one  side,  especially  to 
that  side  on  wliich  the  accumulation  of  chromatic  substances  occurs. 
The  nuclear  membrane  may  be  broken.  (5)  The  nucleolus  is  the  most 
resistant  part  of  the  cell.  It  is  for  the  most  part  jireserved  and  deeply 
stained,  even  when  the  remainder  of  the  cell  is  profoundly  altered.  At 
times  it  may  be  diminished  in  size.  It  has  a  tendency  to  an  eccentric 
position,  being  pushed  out  to  the  periphery  of  the  nucleus  or  even  to 
the  periphery  of  the  cell. 

Corrado  also  describes  a  series  of  changes  in  specimens  treated  by 
the  Golgi  methods.  These  changes  of  the  dendrites  consist,  for  the 
most  part,  of  varicose  atrophy,  fragmentation,  and  other  modifications 
of  shape  and  position.  Since  the  Golgi  method  and  its  now  known 
modifications  show  precisely  such  changes  in  normal  material,  it  is 
fairly  well  estal^lished,  by  reason  of  this  and  also  on  account  of  the 
great  lack  of  uniformity  of  the  Golgi  pictures,  that  it  is  unwise  to  des- 
cribe degenerative  lesions  pathognomonic  of  any  diseased  condition. 
Hence  these  observations  of  Corrado  by  means  of  the  Golgi  method 
will  be  mentioned  only. 

In  man  the  pathologic  features  have  been  closely  followed,  though  not 
as  yet  by  the  newer  methods.  Electrocution  has  given  the  most  accu- 
rately observed  cases,  and  the  investigations  of  Spitzka,  Van  Gieson, 
and  Kratter  are  the  most  elaborate.  In  the  case  of  William  Kemmler, 
the  first  officially  electrocuted  criminal  under  the  modified  statutes  of 
the  Stiite  of  New  York,  the  following  autopsy  record  is  taken  from  the 
notes  of  Dr.  George  F.  Shrady  :  "(/'ai)illarv  hemorrhages  were  noted 
on  the  floor  of  tlie  fourth  ventricle,  tiie  third  ventricle,  and  the  anterior 
part  of  the  lateral  ventricles.  The  circumvascular  spaces  appeared  to 
be  distended  with  serum  and  blood.  The  brain  cortex  beneath  the  area 
of  contact  was  notubly  hardened.     The  vessels  of  the  corpora  striata 

Vol.  I.— 17 


258       DEATH    AND    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 


were  uotably  enlarged  at  different  parts  of  their  ramifications.  The 
pons  was  slightly  softened.  The  spinal  cord  showed  no  gross  lesions." 
The.  abstracted  report  of  the  microscopic  findings  of  Dr.  Spitzka  is  as 
follows :  The  brain,  spinal  cord,  and  }>eripheral  nerves  appeared 
structurally  healthy  in  every  place  examined  except  in  the  anemic  and 
hardened  areas.  The  hemorrhagic  spots  showed  no  vessel  alterations. 
(The  cytologic  changes  described  by  him  are  of  little  moment  viewed 
from  present-day  standards.)  The  vacuolation  of  the  ganglion  cells 
described  are  those  now  recognized  for  the  most  part  as  being  due  to 
manipulative  artefacts,  hardening,  etc.,  and  cannot  be  brought  into  corre- 
lation with  the  later-day  pathology  of  the  ganglion  cell  (Ewing,  Gold- 
scheider.  Turner,  Barbacci,  etc.).      The  histologic  examinations  of  those 

paying  the  electrocution  death-penalty,  made 
by  Dr.  Van  Gieson  and  others,  are  more  ex- 
tended, and  since  newer  methods  of  accurate 
fixation  and  staining  were  iu  vogue,  some  clue 
may  be  gained  as  to  the  amount  of  cellular 
change.  The  details  of  the  visceral  exami- 
nation do  not  need  repeating,  since  nothing 
abnormal  has  as  yet  been  found  in  any  of 
the  viscera  related  in  any  way  to  the  method 
of  producing  death.  Of  the  cases  examined 
by  Van  Gieson,  that  of  Schichiok  Jugigo 
may  be  taken  as  a  type.  "  The  jiia  was 
uniformly  thin  and  moderately  congested. 
The  blood  was  fluid  throughout.  The  ves- 
sels at  the  base  of  the  brain  were  normal. 
The  gray  matter  was  normal.  Floor  of  the 
fourth  ventricle  at  upper  half  contained  some 
dilated  vessels,  and  on  the  left  side  there  were 
a  number  of  minute  radiating  petechial  spots 
from  1  to  2  mm.  in  diameter.  These  small 
petechial  extravasations  show  small  masses 
of  extravasated  red  blood-cells  situated  for 
the  most  part  in  the  perivascular  spaces  just 
beneath  the  ependynia."  The  hemorrhage 
appeared  as  if  a  small  vessel  had  given  way, 
but  whether  such  rupture  was  due  to  the  current,  to  the  muscular  cf)n- 
tortions,  or  to  the  effects  of  manipulation  are  not  determined  by  the 
observer.  In  his  summary  of  autopsy  findings,  after  reviewing  the 
results  of  a  number  of  autopsies,  Dr.  Van  Gieson  notes  the  following  : 
"(1)  The  passage  of  an  electric  current  of  the  pressure  employed  in 
these  cases  (of  approximately  from  1400  to  1700  volts)  and  in  this 
manner  does  not  do  any  damage  to  any  of  the  internal  organs,  tissues, 
or  muscles.  None  of  these  parts  are  lacerated  or  changed  in  volume  ; 
neither  are  there  any  gross  chemical  or  morphologic  changes  or  altera- 
tion of  their  finer  structural  features.  (2)  The  local  thermic  effects  of 
the  electrodes  are  limited  to  the  scarf  skin.     (3)  The  occurrence  and 


Fig.  20.— Showing  the  character 
and  distribution  of  the  petechial 
spots  in  tlie  floor  of  the  fourth 
ventricle  in  the  case  of  Schichiok 
Jugigo  (Van  Gieson). 


CAUSES    OF    DEATH    BY    ELECTRICITY. 


259 


distribution  of  the  minute  hemorrhagic  spots  are  not  uniform  or  con- 
stant features  in  these  cases  ;  and  as  they  are  foinid  after  death  from  a 
great  variety  of  causes,  they  cannot  ])ro])erly  be  regarded  as  positively 
characteristic  of  death   by  this  method." 

Observations  on  man,  which  can  be  used  to  compare  with  those  of 
Corrado  for  dogs,  are  still  lacking.  For  man  it  carmot  thus  far  be  said, 
therefore,  that  the  observations  of  C/orrado  on  dogs  have  been  verified,  etc. 

Causes  of  Death  by  Blectricity. — From  the  time  when  the 
gods  were  displeased  with  the  children  of  men  to  the  present,  sj)ecula- 
tion  has  been  rife  with  the  question  as  to  the  cause  of  death  by  electri- 
city. The  earlier  observations  have  been  collected  by  Arago,'  and  we 
are  indebted  to  him  for  a  large  number  of  interesting  facts.  Among 
the  earlier  observers  John  Hunter  taught  that  death  \vas  due  to  the 
"  instantaneous  destruction  of  the  vital  power."      Brodie  believed  that 


\ 


">^ 


'iE*>-V-tt;^^ 


Fig.  21.- 


':i^^£s^'' 


-Showing  the  eliaracter  and  distribution  of  the  petechial  spots  in  the  floor  of  the  fourth 
ventricle  iu  the  case  of  Schichiok  Jugigo  (Van  Gieson). 


the  action  was  on  the  head.  Edwards  wrote  of  the  disorganization  of 
the  nervous  system.  Robin  claims  that  death  was  due  to  aspliyxia. 
Schneider,  in  1833,  taught  that  the  electric  current  did  not  traverse  the 
body,  but  spent  itself  on  the  surface,  thus  causing  the  extensive  burns, 
and  death  was  due  to  the  shock  of  the  nervous  svstem.  Strieker's 
observations,  commented  on  in  the  section  on  pathology,  were  among  the 
first  series  of  studies  of  the  more  modern  ]>eriod.  Reports  of  autopsies 
are  more  frequent  from  this  time,  and  experimental  work  has  been  greatly 
amplified.  It  is  worthy  of  mention,  in  passing,  that  Priestly,  in  1766, 
and  Fontana,  in  1775,  made  a  number  of  elaborate  experiments. 

The  modern  epoch  of  experimental  work  may  be  said  to  have  been 
inaugurated  by  Nothnagel,  of  Germany,  in  1880,  by  Brouardel,  Grange, 
and  Gariel,  in  1884,  in  France,  closely  followed  by  Brown-Sequard  and 

'  F.   Ara2;o,    Snmmiliche  Werke,    "  Ueber   das    Gewitter, "    Deutsch    von    W.    G. 
Hankel,  Bd.  iv.,  Leipzig,  1854. 


260       DEATH    AXD    INJURIES    BY    LIGHTNING    AND    ELECTRICITY. 

d'Arsonval,  in  1887.  By  Kratter,  in  Germany,  and  by  Biggs,  Donlin, 
Houston,  Jackson,  Knapp,  Peterson,  Robert  and  Terry,  in  America  ; 
with  the  later  studies  of  Tatum,  Jones,  Bleile,  Oliver  and  Bolam,  and 
Cunningham.  From  the  pathologic  point  of  view  the  work  of  Nissl, 
Hodge,  Levi,  Lugaro,  Mann,  and  Corrado  ^  is  to  be  borne  in  mind. 

From  the  foregoing  brief  summary  it  may  be  seen  that  the  entire 
possible  theoretic  ground  was  covered  by  the  earlier  observers,  but  their 
investigations  lacked  the  precise  experimental  evidences  demanded  at 
the  present  time.  The  investigations  of  Nollet,  Grange,  d'Arsonval, 
Peterson,  and  others  mark  the  earlier  steps  in  the  progress  of  the  eluci- 
dation of  our  knowledge  concerning  the  phenomena  of  death  by  electri- 
city, while  the  other  investigators  just  mentioned  have  brought  the 
question  to  the  present  time  with  some  definite  conclusions.  D'Arson- 
val's  and  Brown-Sequard's  earlier  hypotheses  were  received  more  widely 
than  those  of  other  writers,  and  have  been  extensively  quoted,  but 
within  recent  times  many  of  their  conclusions  have  been  questioned. 
D'Arsonval  taught  that  death  was  produced  in  either  of  two  ways,  or, 
perhaps,  by  the  concurrent  action  of  both  :  (1)  By  direct  action  during 
which  the  disruptive  action  of  the  current  produced  mechanical  altera- 
tions in  the  tissues  and  thus  altered  their  physiologic  activities.  (2)  By 
direct  or  reflex  action,  whereby  the  important  nerve  centers  of  the  med- 
ulla were   affected   in   their  j)hysiologic  functions  which  induced  death. 

Brown-Sequard  later  amplified  this  indirect  action  in  the  nerve  cen- 
ters. D'Arsonval  again  brought  up  the  question,  first  promulgated  by 
Grange,  that  the  electric  current  could  bring  about  effects  simulating 
death,  bat  the  subject  could  be  recovered  by  artificial  respiration,  to 
which  reference  M'ill  be  made  further  in  the  discussion. 

Cunningham's  -  very  able  summary  of  the  experimental  data  follow- 
ing the  epoch  of  d'Arsonval  is  here  freely  used.  The  researches  of 
later  writers  clearly  led  to  the  conclusions  that  neither  the  results  of 
experiments  on  animals  with  strong  electric  currents,  nor  the  numerous 
reports  of  pathologic  findings  in  the  bodies  of  men  killed  accidentally  by 
the  electric  currents  of  commerce  or  legally  electrocuted  by  the  high 
tension  current  employed  by  the  authorities  in  New  York  State  are  in 
the  least  corroborative  of  the  hypotheses  of  these  French  investigators. 
Cunningham's  experiments  bear  out  the  conclusions  of  the  later  writers, 
who  find  that  in  the  higher  animals  the  chief  lethal  effect  of  both  the 
continuous  and  the  alternating  currents  is  due  to  their  action  on  the 
heart.  Thus,  in  order  to  bring  about  fatal  results,  very  much  stronger 
currents  are  necessary  when  the  electrodes  are  applied  to  both  sides  of 
the  head.  A  complication  of  the  problem  arises  from  the  fact  that 
death  may  take  place  in  different  ways,  according  to  the  path  traveled 
by  the  electric  current.  Thus  the  work  of  Cunningham  and  others 
has  shown  that  if  death  results  from  the  more  or  less  prolonged  pass- 

'  For  bibliography  of  this  recent  work  see :  Barbacci,  Centralblait  fur  allgemeine 
Patkologie,  17, IS,  1899;  .Jelliffe,  Archives  of  Neurology  and  Psycho-Pathology,  vol.  i.; 
Ewing,  ibid.  ;  Turner,  Brain,  1899. 

^  Cunningham,  New  Fork  Medical  Journal  [loc.  cit.). 


CAUSES    OF    DEATH    BY    ELECTRICITY.  261 

age  of  a  strons:  current  tlirougli  the  exposed  brain  and  upper  spinal  cord, 
the  lethal  effect  is  ])lainly  the  result  of  asphyxia  ;  wliile  in  a  second 
class,  where  the  stream  of  even  a  moderate  cm-rent  traverses  the  heart 
for  a  brief  period  only,  the  deadly  result  is  due  to  the  interference  with 
the  coordinating  power  of  the  heart,  wiiich  takes  place  suddenly  and  is 
permanent,  causing  the  central  nervous  system  to  die  of  anemia.  A 
coroHary  of  this  fact  is  the  indication  that  death  l)y  electrocution  could 
be  caused  in  a  shorter  time  and  with  greater  certainty  if  the  electrodes 
were  so  placed  that  the  greater  part  of  the  electric  current  were  made 
to  traverse  the  heart  directly.  The  cerebrospinal  arc  should  be  included, 
however,  in  the  path  of  the  current  in  order  to  still  the  respiratory  as 
^vell  as  the  cardiac  movements.  As  pointed  out  in  the  section  on  ]iath- 
oloo^v,  the  heart  in  animals  killed  by  electric  current  is  found  to  show  a 
condition  of  "  delirium  cordis,"  or  "  fibrillary  contraction."  This  is  what 
leads  Cunningham  to  assert  that  death  by  commercial  electric  currents,  as 
well  as  death  by  electrocution,  is  due  for  the  most  part  to  the  fact  that 
the  electric  current  induces  fibrillary  contractions  on  the  heart.  The 
summary  of  conclusions  by  Cunningham  is  here  given  :  (1)  Industrial 
electric  currents  which  traverse  the  whole  body  transversely  or  longi- 
tudinally in  sufficient  intensity  kill  because  fibrillary  contraction  of  the 
heart  is  produced,  and  not,  as  has  been  hitherto  surmised,  by  producing 
a  total  paralysis  of  that  organ  or  by  killing  it  outright.  (2)  8uch  cur- 
rents neither  kill  the  central  nervous  system  outright  nor  paralyze  it  in- 
stantaneously. Death  of  the  nervous  system  from  such  currents  is  due  to 
the  total  anemia  following  a  sudden  arrest  of  the  circulation.  (3)  In  rare 
cases,  when  an  electric  current  traverses  only  the  cerebrocervical  portion 
of  the  nervous  system,  in  considerable  intensity  and  for  a  considerable 
length  of  time,  it  may  kill  by  asphyxia,  consequent  on  a  more  or  less 
complete  inhibition  of  the  respiratory  movements,  which  occurs  chiefly 
during  the  passage  of  the  current.  Xo  existing  facts  warrant  the  con- 
clusion that  the  medullary  respiratory  center  is  paralyzed  or  killed 
in  such  conditions.'  (4)  Industrial  currents  are  ])ractically  non-lethal 
to  frogs  and  turtles,  as  the  condition  of  fibrillation  quickly  and  spon- 
taneously disa])pears  from  their  hearts  after  the  current  has  ceased  to 
pass.  Such  animals  can,  of  course,  be  killed  by  the  very  jirolonged 
application  of  a  current  of  moderate  intensity  or  l)y  one  of  enormous 
voltage  and  large  intensity.  (5)  Strong  electric  currents  applied  to  the 
surface  of  the  skin  affect  tiie  heart  in  the  same  manner  as  currents  of 
less  strength  do  when  they  are  ap]>lied  directly  to  the  exposed  heart. 
(6)  It  may  be  possible  for  an  electric  current  of  enormous  intensity  and 
electromotive  force  to  produce  instantaneous  death  either  by  its  disrup- 
tive action  or  by  producing  an  instantaneous  heat  coagulation  of  the 
cellular  constituents  of  the  l)odv.  Industrial  currents  do  not  kill 
instantly,  although,  as  a  result  of  their  action,  death  rapidly  occurs. 
The  experience  of  individuals  who  have  recovered  Irom  severe  electric 
shock  indicates  that  sucli  a  mode  of  death  is  not  a  painful  one. 

^  Corrado's  observations,  while  not  disproviiisi'  tliis  statement,  throw  some  important 
light  on  the  pathologic  processes  taking  place  in  the  medullary  centers. 


262       DEATH    AND    INJUEIES    BY    LIGHTNING    AND    ELECTRICITY. 

Since,  from  a  pathologic  point  of  view,  the  critical  analysis  of  the 
cellular  changes  described  by  Corrado  does  not  enable  one  to  say  what 
the  initial  cause  of  the  cellular  destiaiction  may  have  been,  the  results 
of  physiologic  investigation .  must  be  accepted  ;  and  since  independent 
observers — Cunningham,  Prevost,  and  Batelli — have  come  to  similar 
conclusions,  it  seems  that  the  question  of  the  cause  of  death  by  electri- 
city has  an  authoritative  answer  in  the  conclusions  just  quoted. 

Certain  Questions  of  Death  and  Recovery. — From  all  the 
evidence  at  command,  clinical  observations  and  ex])erimental  data,  it  is 
probable  that  death  takes  place  instantly — /.  e.,  for  all  practical  pur- 
poses. Theoretically  it  can  readily  be  seen  that  if  death  results  from 
secondary  anemia  following  cardiac  fibrillation  it  may  take  a  few  seconds 
for  the  nervous  tissue  to  disorganize.  The  evidence  derived  from  non- 
fatal cases  is,  however,  of  great  interest,  for  here  personal  experience 
with  patients  and  the  writings  of  others  show  that  a  number  of  indi- 
viduals who  have  been  rendered  unconscious  have  recognized  in  the 
brief  moment  of  consciousness  the  experience  of  a  strange  sensation. 
Some  have  recognized  what  the  character  of  the  sensation  was,  and 
the  general  experience  has  been  that  this  sensation  is  not  painful,  but 
is  onlv  an  exatrueration  of  the  uncomfortable  feeling  induced  bv  an 
ordinary  faradic  battery.  As  for  the  sensations  experienced  by  those 
who  have  died,  it  seems  probable  that  if  death  occurs  by  the  method  of 
direct  cellular  disorganization,  no  sensations  are  experienced,  whereas 
if  death  occurs  bv  the  second  method,  that  of  cardiac  fibrilhition  and 
consequent  anemia,  it  is  not  improbable  thaf  some  momentary  recogni- 
tion of  strange  perceptions  mounts  to  the  threshold  of  consciousness. 
Whether  they  enter  the  full  field  of  consciousness  and  give  rise  to  the 
sensation  of  great  pain  must  only  be  surmised,  though  it  seems  probable 
that  such  is  not  the  case  from  the  evidence  to  which  brief  allusion  has 
been  made.  Recoveries  from  the  shock  of  lightning  or  electricity  which 
has  brought  about  unconsciousness  are  very  common.  There  is,  how- 
ever, a  wide-spread  and  natural  lack  of  certainty  in  the  minds  of  tech- 
nical students,  as  well  as  the  laity,  as  to  the  border-lines  which  separate 
the  recoverable  from  the  fatal  cases.  Closely  related  to  this  is  the  prac- 
tical question  of  how  l)est  to  treat  a  ])atient  in  order  to  bring  about 
recovery.  In  the  milder  grades  of  accident  a  certain  amount  of  mus- 
cular fixation  brings  about  a  loss  of  respiratory  movements  with  conse- 
quent asphyxiation.  Recovery  in  such  cases  is  extremely  probable. 
In  the  severer  grades  the  problem  to  solve  is,  whether  there  is  a  point 
where  asphvxia  passes  over  to  the  border  of  cellular  degeneration  or 
whether  cellular  degeneration  is  primary  ?  If  the  latter  lesion  is  pres- 
ent, recovery  is  impossible  and  therapeutic  agencies  futile ;  if  the 
former,  methods  of  stimulation  of  the  respiratory  centers  may  be  of 
benefit,  or,  if  the  heart  is  in  the  condition  of  cardiac  fibrillation,  some 
efforts  should  l^e  made  to  bring  about  coordination. 

Treatment. — In  the  treatment  of  electric  injuries  promptness  is 
imperative.  If  commercial  currents  are  the  cause,  careful  efforts  should 
be  made  to  remove  the  patient  from  the  current  at  once.     The  rescuer's 


TREATMENT.  263 

zeal   should   be    accompanied   l)y   caution.     Some   insulating    material, 
rubber  gloves,  blankets,  or  cloths  should  be  used  in  handling  the  wires. 

External  heat  to  the  body,  artificial  respiration,  and  cardiac  stim- 
ulants should  be  used  simultaneously.  The  method  of  J)r.  P.  J.  Gibbon 
has  been  extensively  employed.  The  patient  must  not  be  touched  with 
the  naked  hands,  but  may  be  dragged  away  by  his  clothing,  or  removed 
from  contact  with  the  eartii  by  slipi)ing  a  board  under  him,  to  break  the 
current,  or  from  contact  with  the  *'  live  wires  "  by  raising  them  with  a 
stick.  As  soon  as  he  is  free  from  the  current,  either  by  the  turning 
it  off  or  bv  the  removal  of  the  patient,  ef["orts  at  resuscitation  should  be 
begun  along  much  the  same  lines  as  are  followed  to  restore  a  drowning 
person.  The  crowd  should  be  dispersed  to  give  the  patient  air.  He 
should  be  laid  upon  his  back,  with  a  rolled  coat  placed  under  the 
shoulders  to  support  the  spine  and  let  the  head  fall  backward.  Then 
anv  well-knoM-n  methods  of  eifecting  artificial  respiration  should  be 
beo-un.  Dr.  Peter  J.  Gil)ljon  says  that  the  two  prime  indications  in  the 
treatment  of  prostration  by  the  electric  shock  are,  first,  to  restore  the 
respiratory  svstem,  and,  second,  to  promote  warmth  and  circulation. 
To  restore  the  respiration.  Gibbon  recommends  the  insertion  of  the 
distal  end  of  the  tube  of  his  aj^paratus  into  the  nostrils  or  mouth. 
This  apparatus  consists  of  a  simple  pair  of  bellows,  so  constructed  that 
when  the  handle  of  the  bellows  is  raised  the  air  rushes  from  the  patient's 
lung  into  one  compartment  of  the  bellows ;  simultaneously  the  other 
compartment  is  filled  with  fresh  air  through  a  tube  on  the  reverse  side. 
The  air  is  forced  into  the  king*?  by  compression  of  the  handles.  This 
instrument,  it  is  claimed,  is  more  certain  and  expeditious  in  restoring 
suspended  respiration  in  persons  who  have  undergone  electric  shock, 
taken  poison,  or  been  long  immersed  in  water,  than  any  other  method 
in  use.  The  nostrils  should  be  excited  with  snuff,  hartshorn,  or  smell- 
ing salts,  any  of  w^hich  may  be  introduced  with  the  fresh  air  into  the 
bellows.  The  tongue  should  be  grasped  with  a  cloth  and  pulled  out, 
thus  stimulating  tiie  sensory  nerves  and  producing  a  reflex  action  on 
the  principal  motor  nerves  distributed  to  the  muscles  of  respiration. 

To  restore  circulation  the  patient  should  be  w'rapped  warmly,  hot 
bottles  or  bricks  being  placed  at  his  extremities,  between  the  thighs,  and 
under  the  arm-pits,  care  being  taken  not  to  burn  him.  He  should  not 
be  rubbed  until  he  begins  to  breathe,  and  on  no  account  should  he  be 
taken  into  a  close,  warm  room.  When  respiration  is  established  the 
limbs  should  be  rubbed  upward  l)riskly.  A  physician  may  insert  the 
distal  end  of  Gibbon's  apparatus  tube  into  the  laryngeal  entrance  or  do 
a  tracheotomy.  He  can  also  keep  up  body-heat  by  means  of  electric 
batteries. 

No  method  should  be  discontinued  under  from  three  to  six  hours. 
Often  no  signs  of  life  are  seen  for  from  one  to  tNvo  hours,  but  are  mani- 
fested later.  Before  giving  up  all  hope,  the  injection  of  an  alkaline 
solution  is  recommended,  as  in  the  case  of  people  who  have  bled  to  death. 
After  artificial  respiration  ceases,  it  may  be  that  nature  fails  to  perform 
its  duty,  and  it  must  be  resorted  to  again  until  life  is  fully  reestablished. 


WOUNDS. 


The  consideration  of  the  injuries  called,  in  ordinary  parlance, 
"  Avounds  "  is  a  matter  of  moment  for  the  medical  jurist.  While  in 
surgery  the  term  is  used  to  designate  those  conditions  where  a  solution 
of  continuity  of  the  skin  or  mucous  membranes  of  the  body  takes  place, 
by  violence  either  from  within  or  without,  in  law  the  word  is  given  a 
wider  meaning,  for  it  is  here  held  not  as  a  technical  w^ord,  but  one  of 
common  speech,  and  consequently  includes  other  conditions  than  those 
accorded  it  by  writers  on  surgery.'  "  Any  lesion  of  the  body,  whether 
cut,  bruise,  contusion,  fracture,  dislocation,  or  burn  "  is  considered  in 
law  a  wound.^  The  words  "  blow  "  and  ''  wound  "  have  been  held  to 
be  synonymous  in  meaning,^  but  the  injury  must  be  one  causing  an 
injury  in  order  to  be  considered  a  wound.  Scratches,  even  if  they  do 
cause  a  certain  solution  of  continuity,  are  not  considered  wounds,  for 
here  the  danger  done  is  slight,  however  much  discomfort  may  be  caused, 
and  wounding  has  not  taken  place,  for  no  ill  effects  are  liable  to  occur.^ 

A  wound,  to  be  one  in  law,  must  be  an  injury  which  does  damage 
to  the  part  affected.  The  cut,  stab^  bruise,  or  break  is  followed  by 
more  or  less  loss  of  power  or  of  substance,  and  may  be,  according  to 
circumstances,  slight,  severe,  dangerous,  or  mortal.  All  are  wounds, 
and  while  the  slight  wound  may  at  first  appear  trivial,  still  it  may 
easily  be  converted  into  any  one  of  the  other  types  by  causes  over 
which  the  person  suffering  it  has  no  control.  The  character  of  the 
w'ound,  therefore,  becomes  of  importance,  the  amount  of  importance  to 
be  decided  by  the  district  attorney,  u])on  the  statement  of  the  surgeon  ; 
for  the  physician  decides  from  his  knowledge  of  such  matters  whether 
no  further  danger  will  in  all  probability  arise  from  the  injury  or 
whether  the  general  state  of  tlie  jxiticnt  is  one  which  will  tend  to  make 
healing  difficult  or  even  to  prevent  it  altogether. 

Care  must  be  exercised,  therefore,  on  the  part  of  the  surgeon  in 
stating  a  prognosis  when  the  wound  before  him  is  the  subject  of  judicial 
inquiry.  An  assault  may  be  committed  and  tlie  victim  rendered  in- 
sensible, say,  by  a  blow  upon  the  head.  If,  shortly  after  the  patient  is 
seen  by  the  physician,  he  rallies  and  aji]iears  to  he  in  fairly  good  condi- 
tion and  the  surgeon  should  give  a  certificate  that  the  injury  is  slight  and 
no  danger  need  be  a})prehended,  trouble  may  arise,  for  in  a  few  days  or 

1  State  vs.  Owens,  1  Murph.  (N.  Car.),  465-4  Am.  D.  C,  571. 

'^  Wharton  Law  Lex.  »  g^.^^e  ,..^.    Noblett,  2  Jones  (N.  Car.),  433. 

*  Reg.  r.s-.  McLaughlin,  8  C.  &  P.,  635-34  E.  C.  L.,  561  ;  Reg.  vs.  Wood,  4  C.  &  P., 
381-19,  E.  C.  L.,  430;  Com.  vs.  Gallagher,  6  Met.  (Mass.),  5G8 ;  State  t)s.  Leonard,  22 
Mo.,  450. 

264 


KINDS    OF    WOUNDS.  265 

even  later  the  patient  may  become  worse,  pass  into  the  condition  of 
coma,  and  die  from  an  abscess  of  the  brain  caused  bv  the  l)h)W  received. 
The  action  of  the  medical  man  in  giving  a  certificate  that  danger  from 
the  assault  was  over  would  be  wrong.  Good  judgment  must  be  exer- 
cised in  this  matter  of  giving  certificates  regarding  injuries.  The 
accused  has  rights  which  must  be  observed.  If,  in  such  a  case  as  is 
here  su})posed,  the  ])atient  is  given  a  sujierficial  examination,  the  pliy- 
sician's  certificate  would  be  procured  on  insutticient  knowledge.  But  if 
care  is  taken  and,  from  his  knowledge  of  such  things  and  the  symptoms 
before  him,  the  doctor  refuses  the  certificate,  he  is  able  to  give  his  rea- 
sons before  the  magistrate  and  will  be  upheld,  if  such  reasons  are  founded 
upon  and  supported  by  the  authorities  on  such  injuries. 

The  evidence  presented  by  wounds  is  to  be  studied  carefully.  The 
character  of  the  wound,  its  probable  method  of  infliction,  the  weapon 
that  could  cause  such  a  lesion,  its  direction  as  to  reception,  whether 
self-inflicted  or  by  another,  whether  recent  or  old,  on  the  living  or  on 
the  dead  body,  must  all  be  taken  into  account.  Wounds  tell  their 
story  in  most  cases  with  no  uncertain  tongue,  and  the  evidence  they 
give  may  be  of  the  utmost  importance.  Too  much  care  cannot  be  used 
in  noting  carefully  every  characteristic  of  any  wound,  its  position  as 
shown  by  relations  to  marked  and  fixed  points  of  the  body,  the  appear- 
ances of  its  edges,  or,  if  a  bruise,  its  color,  the  size  in  all  directions, 
length,  breadth,  and  depth,  and  in  short,  every  appearance  presented, 
that  a  thorough  and  absolute  knowledge  may  be  had  from  which  deduc- 
tions can  be  drawn  as  to  the  manner  and  method  of  infliction.  Refer- 
ence will  be  made  further  on  concerning  this  part  of  the  subject. 

Kinds  of  Wounds. — It  is  best  to  follow  the  usual  division  given 
in  surgical  text-books  for  the  nomenclature  of  wounds,  adding  those 
other  injuries  which  the  law  places  in  the  same  category.  Two  main 
classes  are  given — open  wounds,  or  wounds  open  to  the  air,  and  subcu- 
taneous wounds,  or  those  which  include  all  injuries  unaccompanied 
by  breach  of  the  skin.  "  Open  wounds  are  subdivided,  according  to 
tlie  manner  in  which  they  are  produced,  into  incised,  punctured,  con= 
tused,  lacerated,  gunshot,  or  poisoned  wounds,  according  as  the 
wounding  agent  has  a  siiarp  cutting-edge,  a  penetrating  point,  a  dull 
and  bruising  body,  a  tearing  force,  a  projectile  impelled  by  the  force  of 
an  ex])losive,  or  one  which  carries  with  it  into  the  wound  a  poison."^ 
To  this  we  may  add  fractures  and  dislocations  of  the  bones  and  burns 
l)y  different  agents.  The  wounds  by  missiles  and  by  fire  arc  treated 
elsewhere  in  this  volume. 

It  is  well  to  remember  that  while  wounds  are  divided  into  the  classes 
stated  above,  to  the  lay  mind  a  wound  is  a  wound,  and  but  little  stress 
is  given  as  to  whether  it  is  incised,  lacerated,  or  wliat.  The  medical 
witness,  bearing  this  in  mind,  will  be  understood  more  readily  if  he  is 
Milling  to  use  the  word  wound  as  usually  accepted,  and  not  be  too  tech- 
nical in  insisting  upon  the  descriptive  adjective  being  tacked  on  when- 
ever the  injury  is  described.     Once  having  stated  clearly  the  character 

^  American  Text-Book  of  Surgery. 


266  WOUNDS. 

of  the  wound  and  why  it  is  so  called,  all  reference  to  the  injury  may  after- 
ward be  easily  and  understandingly  made  by  speaking  of  the  wound. 

Wounds  Dangerous  to  I/ife. — It  has  already  been  outlined  that 
a  medical  man  must  be  cautious  in  certifying  as  to  the  nature  of  a 
wound  which  is  the  result  of  a  homicidal  or  criminal  assault.  The 
questions  arise,  What  is  a  wound  that  is  dangerous  to  life  ?  and.  For 
what  length  of  time  is  it  necessary  to  wait  before  giving  a  certificate 
that  such  and  such  a  wound  is  not  one  involving  doubt  as  to  recovery 
therefrom  ?  It  is  perfectly  evident  that  unless  the  danger  from  a  given 
wound  is  immment,  while  the  wound  may  be  a  dangerous  one,  still  life 
may  not  be  immediately  threatened,  and  the  surgeon  must  give  a  quali- 
fied opinion.  It  may  be  that  he  has  been  required  by  the  district  attor- 
ney or  some  other  judicial  officer  to  furnish  this  opinion,  as  the  question 
of  holding  the  prisoner  in  restraint  depends  upon  his  statement.  If  the 
wound  is  one  penetrating  a  cavity,  such  as  the  chest  or  abdomen,  or 
is  of  such  violence  to  the  head  as  either  to  cause  fracture  or  to  render 
death  probable  from  the  concussion,  it  is  perfectly  proper  to  state  that 
the  wound  is  one  dangerous  to  life.  The  reasons,  if  chance  for  cross- 
examination  is  given  the  accused's  counsel,  are  easily  given  by  the 
medical  witness  and  are  conclusive.  But  should  the  wound  be  a  seri- 
ous one,  such  as  Dr.  A.  S.  Taylor  calls  a  "  wound  doing  grievous  bodily 
harm,''  but  not  dangerous  to  life  unless  secondary  complications  arise, 
then  the  physician  could  not  state  that  it  was  of  such  magnitude  as 
those  just  described.  Again,  the  wounding  may  be  so  severe  as  to  raise 
a  doubt  of  its  degree  in  the  minds  of  those  seeing  it ;  still,  when  care- 
fully examined,  although  dangerous,  the  danger  may  not  be  imminent, 
and  the  doctor  so  states.  It  is  apparent,  then,  that  caution  must  be 
exercised  in  giving  a  certificate  concerning  the  danger  to  be  apprehended 
from  severe  wounds,  and  the  surgeon  making  the  certificate  had  best 
set  forth  fully  all  the  facts  about  the  wound  before  him,  and  just  Avhy 
and  when  dangers  from  it  arise,  and  how  much,  in  his  opinion,  life 
is  threatened,  leaving  the  court  and  prosecuting  officer  to  decide  what 
action  should  be  taken  in  such  conditions.  One  caution  to  medical  men 
is  here  inserted,  and  it  holds  good  in  all  they  may  have  to  do,  when  either 
writing  for  or  giving  testimony  before  the  courts,  and  that  is,  to  put 
what  is  written  and  said  in  plain,  simple  English.  While  lawyers  are 
of  the  learned  jirofessions,  they  do  not  pretend,  any  more  than  laymen, 
to  understand  all  the  technical  terms  of  medicine  or  surgery ;  and  to 
dilate  learnedly  upon  a  case  while  a  witness,  using  freely  terms  familiar 
to  the  witness  alone,  and,  after  having  given  so  brilliant  an  exhibi- 
tion of  great  erudition  to  the  crowded  court-room,  to  be  asked  quietly 
by  either  judge  or  counsel  to  "  please  put  that  in  English,  Doctor,  so 
that  ordinary  mortals  may  understand  you,"  does  not  conduce  to  either 
comfort  or  reputation. 

Wounds  on  the  Dead  Body. — All  characteristics  of  a  wound 
on  a  dead  body  must  be  carefully  noted.  The  size,  character,  extent, 
depth,  direction,  and  condition  should  have  attention  ;  for  the  question 
must  be  decided  whether  this  is  a  wound  made  before  or  after  death. 


WOUNDS    ON    THE    DEAD    BODY.  267 

The  further  decision,  Avas  deatli  due  to  the  wound,  is  to  be  made, 
but  this  is  settled  by  the  aut()j)sy,  the  makiii^'  of  which  is  described 
elsewhere. 

Was  the  Wound  Made  after  Death  ? — Certain  wounds  made  upon 
the  living  body  have  different  characteristics  when  made  on  the  cadaver, 
but  the  time  of  infliction  as  regards  the  time  of  death  has  a  marked 
influence  upon  these  tliagnostic  signs.  Su))posing  a  wound — say  a  cut 
of  some  kind — on  a  dead  body  showed  evidence  of  purulent  matter,  tlie 
statement  would  be  positive  that  that  wound  was  made  before  death  ; 
there  could  be  no  doubt  about  it,  for  all  know  that  pus  does  not  form 
in  a  dead  body.  But  if  the  wound  should  present  similar  characters 
on  the  living,  the  question  could  not  so  readily  be  answered.  The 
wound  may  have  been  instantly  mortal,  the  body  living  when  the 
knife  was  driven  in  and  dead  when  the  knife  was  withdrawn.  Here 
no  one  could  say,  except  from  the  probability  that  death  followed  the 
wounding,  whether  the  cut  was  made  before  or  after  death.  Caspar 
mentions  a  case  of  this  kind  in  which  a  woman  was  stabbed,  the 
knife  cutting  the  aorta,  making  death  instantaneous.  If  the  wound  is  a 
cut  and  made  after  the  body  has  been  dead  long  enough  for  most  of  the 
animal  heat  to  have  passed  off,  or  if  postmortem  rigidity  has  set  in  at  the 
time  the  cutting  is  done,  the  characteristics  of  the  wound  as  being  one 
made  after  death  are  fairlv  clear.  The  skin,  havino;  lost  its  contractilitv, 
is  not  everted,  and  the  tissues  do  not  gape  ;  if  blood  is  effused  it  is 
venous  and  coagulates  slowly  if  at  all ;  clots  are  not  found  in  tiie 
wound.  But  where  the  wounding  is  done  immediately  after  deatli,  or 
within,  say,  half  an  hour,  then  the  signs  are  not  so  positive.  Muscular 
contractility  and  that  of  the  skin  have  not  been  lost  at  this  period,  rigor 
mortis  is  still  al)sent,  and  consequently  the  wound  will  have  much  the 
appearance  of  one  inflicted  during  life.  In  fact  it  is  difficult  to  distin- 
guish positively,  and  a  guarded  opinion  has  to  be  given.  In  such 
a  wound  blood-clots,  in  the  cut  are  found,  and  the  clots  are  more  or 
less  attached  to  the  sides.  The  main  point  of  distinction  between  such 
a  woun<l  and  one  made  during  life  is,  whether  in  the  cutting  an  artery 
is  divided.  If  a  vessel  of  fair  size  be  severed,  the  spurting  that  follows 
while  the  heart  is  still  acting  gives  the  peculiar  bleeding  that  tells  of 
arterial  hemorrhage,  and  on  the  surrounding  parts  or  clothing  may  be 
found  the  spots  of  blood  thrown  fi'om  the  vessel.  In  a  like  wound  in 
the  dead,  however,  there  is  no  such  bleeding.  Here  all  the  blood  flows 
by  gravity  and  is  from  the  fulness  of  the  veins  ;  its  color,  when  seen,  may 
be  that  of  arterial  flow,  it  having  absorbed  oxygen  from  the  air,  but  the 
spurting  is  wanting.  While  this  holds  good  where  the  wound  is  such 
that  the  divided  vessel  has  a  chance  to  bleed  in  its  natural  maimer,  the 
wound  may  be  so  made  that  no  s]iurting  takes  place,  the  cut  artery 
being  interfered  with  by  the  sides  of  the  wound.  The  difHeulty  of 
deciding  whether  the  wound  was  made  before  death  or  after  is  in  such  a 
case  increased. 

In  torn,  or  what  are  called  lacerated  wounds,  the  same  difficulty 
exists.     Here  there  is  rarely  as  much  arterial  spurting  as  in  an  incised 


268  WOUNDS. 

or  cut  wound,  for  the  torn  tissues  tend  to  clot  the  blood  and  prevent  its 
being  driven  out  in  jets.  But  another  element  may  come  into  considera- 
tion in  deciding  the  time  of"  reception  of  this  kind  of  wound,  and  that 
is  the  element  of  bruising,  for  frequently  such  wounds,  when  homicidal, 
have  been  made  by  a  dull  weapon,  and  contusion  exists,  with  the  solution 
of  continuity. 

Wounds  that  divide  the  skin  and  deeper  tissues,  if  made  on  the 
dead,  do  not  bleed  so  much  as  those  on  the  living  body.  The  bleeding, 
as  said  before,  is  venous,  and  the  blood  flows  by  gravity.  It  is,  there- 
fore, more  from  a  depending  point  of  the  wound  than  from  its  entirety. 
It  does  not  well  up  and  flow  over  as  in  the  living.  Again,  in  the  dead 
body,  capillary  bleeding  does  not  take  place,  and  this  may  be  an  aid  in 
determining  the  question  as  to  the  time  when  the  wounding  was  done. 

When  the  wound  consists  of  a  confusion  or  bruise  without  the  break- 
ing of  the  skin,  it  is  found  that  unless  it  is  inflicted  upon  the  body 
immediately  after,  or  within  a  short  time  after  death,  the  same  charac- 
teristics as  are  observed  in  a  contusion  on  the  living  do  not  obtain. 
Christison  gives  two  hours  as  the  time  when  blows  upon  the  dead  body 
cease  to  resemble  those  upon  the  living.^  But  experiments  show  that 
to  produce  an  appearance  liable  to  be  mistaken  for  a  contusion  before  death 
the  violence  used  must  be  much  increased,  for  the  capillaries  do  uot 
contain  as  much  blood  after  death  as  in  life,  and  the  ecchymosis  or  dis- 
coloration following  a  blow  is  mainly  due  to  the  rupture  of  these 
vessels  and  the  eff'usion  of  blood  into  the  tissue  of  the  true  skin  or  into 
the  subcutaneous  tissue.  A  bruise,  therefore,  made  after  death,  while 
its  appearance  to  the  eye  will  be  so  similar  as  readily  to  be  considered 
one  that  was  received  during  life,  ^\"ill  usually,  by  the  aid  of  the 
knife,  be  shown  in  its  true  character,  for  the  blood  will  not  be  so  gen- 
erally or  so  completely  difl\ised  in  the  true  skin.  Should  the  violence 
be  done  after  the  body  is  well  advanced  in  cooling,  or  with  rigor  mortis 
marked,  the  determination  of  such  a  contusion  as  postmortem  is  a  much 
easier  task  for  the  same  reasons  as  were  given  when  wounds  involving 
the  solution  of  continuity  were  considered. 

In  fractures  the  tearing  of  dead  muscles  surrounding  the  broken 
bones  does  not  show  the  same  amount  of  blood  as  in  fractures  before 
death,  and  for  the  same  reason  the  bullet-track  differs  from  one  in  live 
tissue.  The  blood  is  not  effused  in  the  same  way  from  dead  vessels  as 
from  live  ones,  and  the  bleeding  around  the  fracture  is  not  only  reduced, 
but  more  circumscribed,  coming  as  it  does  from  some  vein  torn  by  one 
or  the  other  of  the  fragments.  As  in  the  conditi(Mi  just  recited,  care 
must  be  exercised  in  the  giving  of  an  opinion,  and  unless  the  appear- 
ances are  such  as  to  Avarrant  an  unqualified  statement  that  the  wound 
under  consideration  was  inflicted  after  death,  the  most  that  can  be  said 
is  that  the  wounds  were  received  either  just  before  or  just  after  death 
took  place. 

Wounds  on  the  I^iving. — Contusions. — These,  known  in  ordi- 
nary parlance  as  bruises,  are  such  injuries  as  are  inflicted  with  a  dull 

^  Taylor's  Medical  Jurisprudence. 


WOUNDS    ON    TH?:    LIVING.  269 

weapon  like  a  club,  stone,  sand-bag,  billy,  et  genus  omne,^.  While  a 
contusion  may  he  accompanied  by  a  breaking  of  the  skin  and  more  or 
less  tearing  of  the  tissues,  converting  the  wound  into  what  is  called  a 
contused  and  lacerated  one,  the  simj)le  contusion  gives  certain  appear- 
ances which  are  readily  recognized.  At  first  the  effect  of  the  blow  is  to 
cause  a  redness  at  the  point  struck  ;  this  in  turn  is  foUowcd  by  a  darker, 
dusky  red,  which  shortly  turns  to  blue.  This  discoloration  is  technically 
called  ecchymosis,  and  is  the  result  of  blood  being  effused  into  either 
the  tissues  of  the  true  skin  or  into  the  loose  tissue  just  beneath  the  skin, 
from  small  vessels  ruptured  by  the  force  of  the  blow.  This  discolora- 
tion sometimes  does  not  show  until  after  death,  for  in  deep  bruising, 
especially  where  the  blow  has  been  struck  on  some  part  not  having  bone 
behind  it,  such  as  the  abdomen,  the  ecchymosis  does  not  show  for  some 
hours,  and  at  times  there  is  no  evidence  of  violence  in  the  skin.  But 
where  the  blow  has  been  receive ed  on  a  part  covering  bone,  thus  giving 
a  firm  base  against  which  the  force  f)f  the  blow  acts,  the  distinctive 
appearance  of  the  bruise  will  show  readily  and  rapidly,  a  half-hour 
being  long  enough  time  to  produce  discoh^ration.  And  should  the  blow 
struck  })rove  mortal,  the  ecchymosis  would  follow  in  a  short  time ;  con- 
sequently it  is  not  to  be  held  that  such  bruises  proved  that  the  assailed 
lived  long  enough  for  the  discoloration  to  show.  When  the  bruise, 
then,  presents  but  a  red  or  dark-red  center,  or  a  blue  color,  the  decision 
that  such  a  blow  was  received  during  life  must  be  cautiously  made.  A 
blue  ecchymotic  spot — for  after  death  the  red  turns  to  blue — niay  be 
said  to  have  been  made  shortly  before  death  or  immediately  after.  The 
other  circumstances  surrounding  the  death  would  have  weight  in  the 
decisi(^n.  If  a  bruise  shows  other  color  than  the  blue,  then  it  is  posi- 
tive evidence  that  it  was  inflicted  during  life,  for  when  the  blood  effused 
by  the  blow  clots,  we  have,  as  the  clot  contracts,  serum  effused,  this 
followed  by  inflammation  which  gives  us  the  raised  tissue  and  the 
various  colors  assumed  by  the  bruise :  blue  to  nearly  black,  then 
purple,  violet,  green,  yellow,  and  so  fading  to  the  natural  color  of  the 
skin. 

The  ecchymosis  that  follows  a  blow  appears  within  a  few  minutes 
and  in  the  same  spot  where  the  stroke  lights,  if  bony  structure  is  behind 
the  muscular  tissue.  But  when  the  force  is  transmitted  to  the  deeper 
parts,  or  when  a  fracture  is  caused  by  the  violence,  the  bruise  does  not 
show  sometimes  for  twenty-four  or  thirty-six  hours  and  even  more,  and 
then  at  a  point  distant  from  the  injury.  Here  the  effusion  of  blood, 
being  in  the  deeper  tissues  and  not  under  the  skin,  nuist  take  time  to 
come  to  the  surface,  and  it  follows  the  laAv  of  least  resistance,  being 
guided  in  its  course  by  the  covering  membrane,  or  fascia,  of  the  parts 
where  the  effusion  takes  place.  This  is  to  be  borne  in  mind,  for  as  in 
bruises  which  show  shortly  after  death  from  violence  done  before  death, 
So  does  this  ecchymosis  from  deep  bruising  make  its  aj)j)earance  when 
life  has  ceased,  even  though  the  assailed  has  lived  for  a  day  or  two  after 
the  assault. 

As  already  said,  no  ecchymosis  may  follow  a  blow  upon  the  abdomen. 


270  WOUNDS. 

The  tissue  here  is  yielding,  having  no  firm  support,  and  the  force  of  a 
blow  is  carried  on  through  the  organs  lying  in  its  track  until  it  is 
expended.  This  force  may  be  so  severe  as  to  cause  rupture  of  the  liver, 
kidneys,  spleen,  bladder,  or  intestines,  and  yet  no  evidence  appear  ex- 
ternally. The  autopsy  discloses  the  condition  and  most  probably  shows 
the  fact  that  such  injuries  have  been  received  dia-ing  life.  Indirect 
violence  due  to  falls  will  also  cause  like  ruptures  of  the  internal  organs, 
but  the  history  of  the  case  will  generally  clear  up  the  origin.  Falls 
also  cause  bruises  to  other  parts  of  the  body  similar  to  those  made  by 
weapons,  and  the  medical  examiner  has  to  weigh  all  the  evidence  he 
can  collect  as  to  the  probable  cause  of  the  injury  before  he  can  give  an 
opinion.  At  the  most,  in  many  cases,  he  may  say,  "Such  an  injury 
could  be  caused  by  a  weapon  similar  to  the  one  produced,  or  by  others 
of  like  character,  or  a  fall  ccndd  have  produced  it,  for  there  is  nothing 
about  the  injury  per  se  that  wonld  decide  how  it  was  inflicted." 

Contusions  from  a  sand-baer  eive  no  trace  on  the  outer  surface  even 
though  the  bone  lies  close  to  the  skin.  The  sand  not  being  tightly 
packed  in  the  bag,  spreads  out  at  the  moment  of  contact,  thus  avoiding 
any  direct  point  of  force,  and  as  it  yields  in  this  way,  the  capillaries  of 
the  skin  escape  rupture ;  but  deeper  tissues  may  be  found  to  have 
blood  effnsed  in  them  and  ecchyniosis  may  eventually  appear.  Even 
harder  substances  may  have  this  same  effect.  In  1895  I  was  asked  by 
the  district  attorney  of  Albany  County  to  make  an  examination  of  the 
body  of  a  man  named  Near  who  had  been  found  dead,  and  circum- 
stances pointed  to  homicidal  assault.  The  coroner's  physician  had 
already  held  an  autopsy,  but  the  prosecuting  officer  was  not  satisfied 
with  his  rej^ort.  It  was  stated  that  the  man  was  jumped  upon.  He 
was  drunk  at  the  time,  and  while  clots  were  found  effused  over  the  brain, 
it  was  stated  they  were  due  to  an  apoplexy  induced  by  alcohol.  No 
dissection  had  been  made  of  the  neck  or  shoulders,  the  part  claimed 
to  be  injured  by  the  feet  of  the  prisoner.  On  dissecting  the  back  of 
the  neck,  two  clots  were  found  situated  near  to  the  spinous  process  of 
the  fifth  cervical  vertebra.  No  marks  of  external  violence  on  the  neck 
were  present.  The  assault  had  been  committed  about  nine  in  the  even- 
ing, and  the  man  was  reported  to  have  been  found  dead  next  morning 
at  seven.  The  spinal  cord  was  completely  surrounded  by  blood-clots  ; 
here  violence  had  undoubtedly  been  done  to  the  neck  and  back  and 
deep  effusion  had  followed,  but  no  external  bruise  or  abrasion  even  was 
present.  The  jumping  was  sworn  to  by  one  witness  who  was  present 
in  the  place  where  the  assault  was  committed,  and  it  is  jirobable  that 
the  absence  of  bruising  was  because  of  the  clothing.  Whether  this 
hypothesis  was  correct  could  not  be  settled.  The  fact  remained,  how- 
ever, that  clots  were  found  in  the  deep  tissues  of  the  neck  and  some 
force  must  have  been  applied  that  could  produce  them. 

Wounds  by  Sharp  Instruments. — Incised  Wounds. — Any  instru- 
ment or  weajion  that  Avill  cut  the  skin  by  a  sharp  edge  makes  what  is 
called  an  incised  wound.  In  felonious  assaults  knives,  swords,  hatchets, 
axes,  or  some  similar  weapon  is  used,  but  tin,  glass,  sheet  iron,  a  sharp- 


WOUNDS    BY    SHAKP    INSTRUMENTS.  271 

cclg;ed  piece  of  wood  are  all  capable  of  makinir  ^n  incif;ed  wound. 
Heavy  weapons,  such  as  hatchets,  axes,  or  the  like,  not  only  cut, 
but  also  crush,  and  we  have  the  element  of  contusion  entering  into  such 
a  wound.  If  the  cutting-edge  be  dull,  then  the  appearance  of  the 
wound  {)artakes  somewhat  of  the  nature  of  a  contused  and  lacerated 
one.  The  a[)pearance  of  an  incised  wound  suggests  the  character  of 
the  weapon  used.  A  cut  made  by  a  razor  or  a  surgeon's  knife  would 
be  finer  and  cleaner,  generally  speaking,  than  a  cut  made  by  a  thick- 
bladcd  knife.  An  incised  wound  gapes ;  the  extent  of  the  gaping 
depends  upon  the  position  of  the  wound  as  regards  the  muscles,  as  a 
cut  made  transverse  to  the  muscular  fibers  opens  more  than  one 
in  the  line  of  filler.  This  gaping  takes  place  as  soon  as  the  wound  is 
made,  for  the  muscle,  irritated  by  the  pain,  contracts,  and  as  a  result 
the  lips  of  the  wound  are  drawn  apart.  The  skin,  elastic,  also  springs 
under  the  knife,  and  by  the  manner  in  which  it  is  divided,  the  begin- 
ning and  ending  of  the  cut  can  be  told.  The  muscles  retracting  in  the 
manner  stated,  the  skin  is  also  pulled  apart  and  rolls  a  little  outward, 
giving  an  everted  appearance  to  the  edge,  showing  the  tissue  lying 
between  the  skin  and  the  muscles.  This  general  appearance  is  the 
same  on  a  wound  made  in  the  dead  l)ody  immediately  after  death,  for 
then  muscular  contractility  has  not  been  lost  and  the  same  condition 
prevails  as  in  life,  excepting,  as  has  before  been  noticed,  the  l)leeding. 
In  life  this  latter  depends  upon  where  and  how  deep  the  cut  is  and 
whether  arteries  are  severed. 

Some  ye